Tubal Sterilization

Excerpt

Tubal sterilization is the intentional occlusion or partial or complete removal of the fallopian tubes to provide permanent contraception in females. Sterilization is highly effective at preventing pregnancy and is the most commonly used form of contraception worldwide. The procedure is indicated when it is desired by the patient for permanent contraception. It can be performed at any time during the menstrual cycle, during cesarean delivery, and in the immediate postpartum and postabortal periods. A large percentage of sterilization procedures worldwide are performed in the immediate postpartum period, including nearly half of all sterilization procedures performed in the US. Procedures performed outside of the immediate postpartum or postabortal period are known as interval procedures. Presently, tubal sterilization is performed laparoscopically or through a mini-laparotomy. Previously, hysteroscopic devices have also been used; however, these devices are no longer available.

Traditionally, interval sterilization was most often accomplished by laparoscopically occluding the tubes with clips, bands, or electrocautery, while postpartum sterilization was typically accomplished via partial salpingectomy through a mini-laparotomy. More recently, however, complete bilateral salpingectomy has become the sterilization procedure of choice during interval and postpartum procedures because it decreases the risk of epithelial ovarian cancer and post-sterilization contraceptive failure compared with traditional sterilization techniques without increasing surgical risk. A 2023 study comparing opportunistic salpingectomy to standard bilateral tubal ligation following vaginal delivery showed that for every 10,000 patients, "salpingectomy would result in 25 fewer ovarian cancer cases, 19 fewer ovarian cancer deaths, and 116 fewer unintended pregnancies than tubal ligation."

During the consent process, clinicians should stress to patients that this procedure is intended to be permanent and that reversal is not always possible. Young age at the time of sterilization is the strongest predictor of regret, with the probability of regret estimated to be between 12 and 20% in individuals sterilized before age 30. To minimize this risk, the entire spectrum of alternative contraceptive options should be reviewed with the patient, with an emphasis on long-acting reversible contraceptives (LARCs), including the intrauterine device (IUD) and contraceptive implant, both of which have efficacy rates similar to traditional tubal sterilization techniques. For patients in a monogamous relationship with a single male partner, vasectomy is another essential alternative to consider because the procedure is associated with lower risks than tubal sterilization.

Although rare, post-sterilization pregnancy can occur. The cumulative 10-year failure rate of tubal sterilization using traditional occlusive methods or postpartum partial salpingectomy ranges from 7.5 to 54.3 pregnancies per 1,000 sterilization procedures, depending on the technique used and the age of the patient at sterilization, with younger ages being associated with higher rates of contraceptive failure. Of note, data on the long-term failure rates of complete bilateral salpingectomy are not yet available, but rates should theoretically approach zero. If post-sterilization pregnancy occurs, there is a relatively high risk of a resulting ectopic pregnancy. As with any surgical procedure, other procedural risks include bleeding, infection, injury to nearby organs, and wound and anesthesia complications. Therefore, due to the importance of permanent sterilization on women's health, healthcare professionals should recognize the indications and contraindications for tubal sterilization; the risks, benefits, and complications of the procedure; the techniques available to perform this mode of sterilization; and the role of the interprofessional team in caring for patients who undergo the type of surgery.