Permanent Birth Control or Sterilization

There are important personal questions that must be considered before something as permanent and profound as sterilization is undertaken. People are the most important aspect of our lives. Family are usually our most important people, and one's fertility most generally determines the composition of one's family. Certain religious traditions are pronatalist, which means they favor family size to be determined naturally, without the practice of contraception. However, more commonly, couples have some preconceived idea of how many children they want to have. Ideally a couple would have a vision of how they would like their life to be, including children, work, and recreation. Ideally every baby would be prepared for, eagerly awaited, joyously received, and properly cared for. I have been in practice since 1994, and though the vast majority of babies I have delivered have been warmly received, a significant percent of them came after the desired family size was reached. 

Barriers to sterilization are very individual, and may stem from genuine ambivalence, relationship issues, cost considerations or misconceptions. We feel that when a woman is simply provided with accurate information about all her options, permanent or reversible, that she will most likely find her own comfort zone and make a sound decision for herself and her family. Providing that information is the purpose of these pages. 

To understand sterilization, one has to review basic anatomy.

Female sterilization

Female pelvic anatomy is best introduced with pictures:

As you may recall from " Menstrual Cycle 101 " eggs are ripened in and released from the ovaries, a process called ovulation. Normally, after ovulation, they are swept up by the tubes where they have the chance to be fertilized by a sperm. To make a pregnancy, the egg must ovulate, pass down the tube, be fertilized by a sperm and implant in the lining of the uterus called the endometrium. To prevent pregnancy, this process can be interrupted anywhere along this progression. You already know that some forms of birth control prevent ovulation. Although these methods are generally very effective, they are not perfect. To surgically block the fallopian tubes entirely is much more effective, and basically permanent. This is what is done in the operation commonly referred to as "tying the tubes". Surgical blockage of the fallopian tubes can be accomplished three ways: 

1. Postpartum tubal ligation - done generally the day after the baby is born, under spinal or general anesthesia, through a small incision under the belly button. It does not necessarily add a day to the hospital stay. 

2. Laparoscopic bilateral  tubal ligation LS BTL  - done as an outpatient surgery with a laparoscope, anytime outside of pregnancy or six weeks or more postpartum, under general anesthesia, with 2 or 3 small incisions on the abdomen. A laparoscope is a small scope to look inside the abdomen.  

Click here for the LS BTL information sheet. 

In these two procedures listed above, there are a variety of ways to block the tubes. They can be banded, cauterized or burned, or tied and cut. Choosing is a matter of fitting the surgical techniques to each patient's individual anatomy and to each surgeon's experience. 

3. Essure - A tubal occlusion procedure using small coils, done with a hysteroscope, anytime outside of pregnancy or six weeks or more postpartum, using local anesthetic and sedation in an office procedure room.  A hysteroscope is a small scope to look inside the uterus through the opening of the cervix. In this technique, the cervix is dilated, a scope is place, and the inner openings on the tubes into the main uterine cavity are visualized. Small coils are then placed into each opening. Over the next three months tissue grows into the coils blocking the tube. A dye study (hysterosalpingogram, HSG) is done at three months post procedure to confirm tubal blockage.  

These sketches give a basic idea of the possible incisions in each case. Note there are two ways to do a laparoscopic tubal ligation, one with the scope and one port, and one with the scope and two ports.

Postpartum tubal            Laparoscopic tubal  #1                   Essure                      Laparoscopic tubal  #2 

All tubal occlusion procedures have the potential to cause heavier or crampier periods. It is believed that some menstrual flow normally exits the tubes. When tubes are blocked, more must come out the cervix, possibly accounting for the change in periods. 

All tubal occlusion procedures come with an increased risk of ectopic pregnancy. If a pregnancy does occur after tubal surgery, it has a much more significant chance of implanting in the the tube since the tube will not be in a normal state. This is called a tubal pregnancy or an ectopic pregnancy, and it is potentially life threatening, since it can cause the tube to rupture and hemorrhage. Any woman suspecting she could be pregnant after a tubal procedure should be evaluated immediately for an ectopic pregnancy. 

The photo at right is of a small tubal pregnancy which was removed at surgery. 

Vasectomy, or male sterilization

This is the procedure of tying the vas deferens to sterilize a male. As seen in the diagram below, the vas deferens are tubes which brings the sperm to the semen. 

When the vas are tied, there is semen ejaculated like usual, but it contains no sperm. Without sperm, pregnancy cannot occur. As the diagram also demonstrates, the vas deferens start near the surface of the back of the scrotal sac. They are therefore surgically accessible. This makes the procedure relatively simple. It is usually done in the office under local anesthetic. Family doctors, general surgeons, and urologists perform vasectomies.  

The only thing a vasectomy does is prevent sperm from reaching the semen. It does nothing to hormones, sex drive, or other sex characteristics such as the pitch of the voice. If a man is considering a vasectomy, he should have a consultation with his provider before the procedure is planned, to learn more about the risks and benefits of the procedure. 

All forms of sterilization, for men and women, are to be considered permanent. However, that is not to say that they cannot fail. The approximate failure rate of all sterilization procedures, is, more or less, 1/300. This is what 1 in 300 looks like : 

Those considering sterilization need to be at least 21 years of age. Studies show that those who are younger are statistically likelier to have regret after their procedure.

Your provider will want to know you have considered your choice for more than a short time, and that you are sure about it even if your relationships and family structure changes. If your insurance is Medicaid, you will have to have signed consent papers at least 30 days but not more than 180 days in advance. 

Permanent birth control is a safe and elegant choice for many women and their families. Call us to learn more.