So you think you need . . . A tubal ligation

Female sterilisation is touted as a safe and hassle-free means of permanently ridding yourself of having more children, particularly for the over-40s. Although doctors usually tell women that tying your tubes is ‘Band-Aid’ surgery, there’s nothing straightforward about the outcome. A growing body of evidence reveals serious long-term problems, including the possibility of indefinite pain.

What is tubal ligation?
This is the most popular form of contraception worldwide. In the US, 34.6 per cent of married women undergo this surgery while, in the UK, 29,300 women were so sterilised in 2001.

The operation, which involves blocking the fallopian tubes to stop eggs from reaching the uterus, is most commonly done by laparoscopy under a general anaesthetic. The laparoscope, through which the surgery is performed, is carried out through a very small incision.

The second method is a mini-laparotomy, which requires a larger incision in the abdomen. Also done under general anaesthesia, the patient needs to spend a couple of days in hospital.

The fallopian tubes can be blocked by a number of means. Clips cause scarring, or fibrosis, of the tube (see box, page 11). The modified Pomeroy technique involves cutting and removing a section of tube. Bipolar cautery burns a section of tube with an electrical current running through the jaws of specialised forceps. Silastic rings separate off a loop of the tube with a stretchy silastic band, and silicone rings are similar. A fimbriectomy removes the far end (the fimbria) of the tube. The Irving and Uchida methods involve removing a section of tube and embedding the cut ends into the wall of the uterus (difficult to reverse).

In general, only one in 200-500 operations fail, although the failure rate may be as high as 3 per cent. Recovery usually takes about a week.

Although TL is available on the NHS in the UK, if you decide you want to reverse the procedure, you will have to pay for it. Prices vary widely: in the UK, TL reversal can cost as much as £4000 on BUPA; in the US, although the initial procedure costs around $2500, reversing it may set you back as much as $5600.

What doctors tell you

* The procedure can fail. One report gave a pregnancy-after-sterilisation figure of 0.9 per cent (out of 311,960 women) (Obstet Gynaecol, 2003; 101: 677-84). The operation can self-reverse on its own, but this is less likely over time.

* You may come to regret your decision. Sterilisation is usually irreversible, especially after the first few years. It’s important to be clear that it’s really what you want – forever. “Think about how you would feel if your children were killed or you have a new partner,” says Dr Patrick O’Brien, consultant at the University College Hospital in London.

* There are some well-known complications, for instance:

* a 0.2 per cent risk of bleeding, especially with a laparotomy, which means a longer recovery time and a bigger scar

* a 30-80 per cent chance of an ectopic pregnancy (outside the uterus, usually in the fallopian tubes) if the procedure fails (Obstet Gynecol Clin North Am, 1999; 26: 83-97), which, if not detected early, can rupture, bleed and even be fatal

* a one in 1000 risk that the laparoscopy equipment will damage the internal organs, requiring an open operation and a hospital stay of perhaps as long as a week

* a risk of permanent infertility even after TL reversal. Although 61 per cent (of 4369 women) did fall pregnant after sterilisation reversal, only 48 per cent carried the baby to term (Obstet Gynaecol, 2003; 101: 677-84).

What doctors don’t tell you

* There’s a 5-25 per cent chance of experiencing post-tubal ligation syndrome (PTLS). First described by US women’s-rights advocate and medicolegal advisor Dr Vicki Hufnagel, PTLS causes pelvic pain, bleeding and abnormal menstruation (Fertil Steril, 1998; 69: 179-86). One in four suffer heavy menstrual bleeding after the operation. Other symptoms may require further gynaecological surgery, including hysterectomy.

* Different methods have different rates of success, and are more or less likely to cause hormonal problems. However, bands, clips and bipolar cautery have eliminated many of the serious complications and, although perhaps less effective than cautery or the modified Pomeroy technique (Fertil Steril, 1984; 41: 337-55), they are also known to cause less damage (see box, page 11).

* You could suffer from premenstrual tension as part of PTLS or simply due to hormonal changes (Fertil Steril, 1998; 69: 179-86).

* You could undergo a premature menopause, with ovarian dysfunction, menstrual and menopausal symptoms, and osteoporosis (Osteoporos Int, 2004; Sep 29 [epub ahead of print).

* You could end up with a hysterectomy due to menstrual disorders following TL (Gynecol Obstet Invest, 1983; 15: 119-26). Women sterilised before 30 are more likely to have such problems and are three to four times more likely to need a hysterectomy.

* You could die under general anaesthetic – it’s a one in 250,000 chance. Other anaesthesia risks include chest infections, breathing difficulties and inhaling your stomach contents.

Mita O’Conaill