Female sterilization refers to the occlusion, destruction, or removal of the Fallopian tubes for the purpose of permanently preventing future pregnancies. This form of contraception was introduced in the 1800s. Over the following decades, the procedure has evolved to increased efficacy and popularity. In the United States, 25.1% of all women use female sterilization as their preferred method of birth control. After the use of oral contraceptive pills, female sterilization is the most widely practiced form of contraception in the United States among married couples. The popularity of the procedure expanded during the 1960s, when it was accepted as an elective procedure and a medical indication was no longer a prerequisite.¹ Currently, approximately half of all sterilization procedures that occur in the United States occur in the inpatient setting. In the inpatient setting, approximately 10% of women choose to have sterilization in the postpartum period.²

The sole indication for female sterilization is a desire by the patient for the procedure. This desire may be motivated by medical or social factors.

IDENTIFYING APPROPRIATE CANDIDATES

Any adult female who expresses a desire for sterilization and also has a clear understanding of the risks, benefits, and alternatives to the procedure is a potential candidate. The payer of the procedure, however, may place additional stipulations that will need to be met in order to allow payment. For instance, US government–paid insurance (i.e. Medicaid) has added restrictions beyond those required by private payers. Appropriate candidates are women who do not wish to have future pregnancies, have no medical contraindications to surgery, and have been counseled appropriately regarding the limits, benefits, and risks of female sterilization, including the potential for regret. Contraindications (listed in Table 58-1) include medical contraindications for undergoing an elective procedure. Relative contraindications include obesity. Those patients with truncal obesity may pose a challenge in accessing the Fallopian tubes in postvaginal delivery sterilization. During a cesarean section (C-section), a patient who is medically or surgically unstable would not be a good candidate for an elective surgical procedure. Other relative contraindications include excessive blood loss associated with delivery.

Ideally, the patient would have been counseled about and gave her consent for postpartum sterilization during the prenatal period. Absolute contraindications for female sterilization include the patient’s lack of desire to undergo the procedure. The procedure should not be performed on patients who are being coerced or who show ambivalence toward the procedure. A patient who does not have the ability to comprehend the counseling and make an informed decision should not undergo the sterilization procedure.

In the ideal setting, postpartum tubal ligation will be discussed during the prenatal period with the antenatal care provider. In all states, patients who are recipients of Medicaid are required to sign a consent form at least 30 days prior to the performance of the procedure.³ This requirement was originally put in place to protect women from being sterilized against their will. This became a common practice when the practice of eugenics gained popularity. However, as women with private insurance do not have to meet this requirement, this government mandate has created an inequality in the ability to access care. It can be surmised that women needing federal funding for healthcare would have more difficulty accessing prenatal healthcare and this counseling may be neglected, or indeed, that the patient may present too late in her pregnancy to meet the time requirements set forth by Medicaid. Data gathered on about 1500 women shows that nearly half of patients who desired sterilization and did not receive it became pregnant within a year of their last delivery.⁴ The major elements that constitute informed consent for this procedure are given in Box 58-1.

In women under 30, it is especially important to counsel about the possibility of regret. Approximately 1 in 5 women under 30 who undergo sterilization experience regret in the 14 years following sterilization.⁵ In these women, long-acting reversible contraceptives (LARCs) may be a more appropriate choice. In addition, counseling should include the inability of sterilization to protect a woman from sexually transmitted diseases, the possibility that the procedure may fail, and alternative forms of contraception.

RISKS

Like all surgical procedures, bleeding, infection, damage to surrounding structures (including the bladder, bowel, and major vessels) and anesthesia are the primary risks of female sterilization. Particular to bilateral tubal ligation (BTL) are the risks of failure and ectopic pregnancy. The US Collaborative Review of Sterilization found that the rate of ectopic pregnancy over 10 years was approximately 7.3 per 1000 procedures, and that the failure rate was 13 per 1000 for all types of sterilization methods, regardless of the surgical approach (laparoscopy vs. mini-laparotomy).⁶ Like intrauterine devices (IUDs), BTL has a significantly lower total rate of pregnancy compared to women who use no form of contraception. The risk of ectopic pregnancy, however, is increased.

Posttubal Sterilization Syndrome

Posttubal sterilization syndrome is a change in menstrual cycle, including increase or decrease in flow, pain with menses or intermenstrual spotting following sterilization. There have been reports of patients experiencing a change in their menstrual cycle following their sterilization procedure.^7,8 While the majority of women do not experience this, and the science is unclear, it should be noted that a minority of patients have reported some changes in their cycles, including an increase or decrease in menorrhagia, dysmenorrhea, and intermenstrual spotting. No particular group or risk factors have been identified as being associated with posttubal sterilization syndrome. Thus making it difficult to identify patients at risk for this complication pre-operatively. It is therefore prudent to alert all patients to the potential risk of this complication.

Pelvic Pain

Up to 26.8% of women report having chronic pelvic pain 24 months after laparoscopic sterilization.⁸ It is important to note that women who experience chronic pain prior to surgery are more likely to report chronic pain after surgery. The same holds true for a diagnosis of abnormal uterine bleeding.⁹ For this reason, sterilization should only be performed for the benefit of permanent contraception.

Postablative Sterilization Syndrome

For women who have undergone an ablation procedure, there may be a risk of experiencing abdominal pain after their tubal ligation. This is often referred to as postablative sterilization syndrome. This risk has been reported to be as high as 10%.¹⁰ It is felt that ablation, along with BTL, causes hematometra with tubal distension, leading to cyclical abdominal pain. Treatment may require surgical removal of the Fallopian tubes or hysterectomy. Women with abnormal uterine bleeding, who may have a high likelihood of receiving an ablation in the future, should be counseled about this possibility. While sterilization is not a contraindication for ablation procedures, it does increase the risk of experiencing a negative outcome.

BENEFITS

Sterilization is an excellent option for those women with satisfied parity. It precludes the necessity for alternative forms of contraception that require follow-up or replacement for the duration of the reproductive period. In addition, with a failure rate of approximately 1%, it is a dependable and safe form of birth control.⁶ In the setting of C-section, no other procedure is necessary. In the setting of vaginal delivery, performing a BTL does not increase the length of the hospital stay. Performing the procedure as an inpatient allows women to have sterilization when desired and prevents the assumption of risk once a patient is discharged postpartum and is faced with scheduling an operation as an outpatient.