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Female sterilization is a widespread means of permanent contraception for women. There are different methods to achieve this, but the woman should always receive careful counseling to ensure she understands and is willing to accept the non-reversible nature of the procedure.
Considering all the techniques, female sterilization is 99 percent effective and may be performed post-partum (along with a Cesarean section), or when the woman is non-pregnant (termed interval sterilization). When compared to male sterilization, female sterilization is pursued three times more frequently.
Electrocoagulation of the tube was the first method involved. Later, tubal ligation became popular. Other widely used techniques include the use of the Filshie clip, or bands, to achieve tubal obstruction. Fimbriectomy was another procedure adopted to reduce the possibility of post-sterilization pregnancy.
Female sterilization depends upon introducing a discontinuity into the fallopian tubes, thereby preventing contact between the oocytes and sperm, and subsequently, fertilization of the oocytes.
Tubal ligation involves transection of the tubes after ligating them on each side of the proposed division site. Sometimes the divided ends are sealed by electrocautery as well. Laparotomic or laparoscopic tubal ligation may be carried out by one of several ligation-excision methods.
Tubal ligation has shown to be highly effective, albeit the end-result may vary depending on the ligation method used, as well as the patient’s race, ethnicity and age. This method also confers protection against the ovarian cancer and reduces the risk of pelvic inflammatory disease.
Tubal implant is a technique which positions a tiny coil (Essure implant, a class III device) shaped like a spring, into each tube, which induces scar formation, thereby blocking the cavity of the tube. This may take up to three months, during which backup contraception must be used. Confirmation of tubal obstruction is sometimes done by contrast radiography.
The coils are placed using a transcervical guide wire introduced by hysteroscopy through the vagina and uterus, which means there are no surgical incisions - i.e. it is a less invasive method to achieve permanent female sterilization.
Essure implant was initially approved in 2002 on the basis of prospective, non-randomized clinical trials. Since then there was a substantial rise of device popularity, most notably in the US. However, from 2013 onwards a sudden increase in the patient-reported adverse events related to this device has been observed.
In 2015, the US Food and Drug Administration (FDA) thoroughly reviewed the scientific literature, together with pre-marketing and post-marketing data, and concluded that not enough evidence is available to withdraw this device from the market.
Still, the FDA released a new guidance document where (from now) a black box warning is required; also, a new postmarketing study to compare Essure’s efficacy and safety with laparoscopic tubal sterilization will be conducted.
Female sterilization has several advantages when carried out properly. The ones that stand out are small rates of morbidity and mortality, permanent and effective contraception results, no need for male partner participation, as well as reduced incidence of ovarian cancer and PID (as already mentioned for tubal ligation).
Nevertheless, short- and long-term complications may occur following female sterilization. Short-term complications are mostly associated with tubal ligation and include infection, pain and bleeding.
Long-term complications may also occur, most notably recanalization of the tube leading to pregnancy (either uterine or extrauterine), which occurs mostly in the first year following sterilization.
Post-sterilization regret, abdominal pain, dyspareunia (i.e. painful sexual intercourse), menstrual disturbances and higher rates of hysterectomy are also considered long-term complications. Other disadvantages include the lack of protection against sexually-transmitted infections.
The efficacy of female sterilization is approximately 99 percent. Post-ligation rates are about 19 per 1000. Post-implant rates appear to be still lower. Spring-clip application rates are approximately 37 per 1000.
Failure of sterilization depends upon patient selection, procedure chosen, surgical skill, and the access route. Being a younger age may also play a role, as these women have increased fertility rates.
The highest rates of post-sterilization pregnancy are seen with a culdotomy approach – this is used in cases where abdominal incision is not an option for tubal occlusion, and is a more difficult procedure which requires a skilled gynecologic surgeon.
In contrast, the lowest rate of post-sterilization pregnancy is seen following thermal coagulation – an electrically safe procedure in which a low voltage is applied to cause division of the fallopian tubes.
Original article reviewed by Afsaneh Khetrapal, BSc (Hons)
Additional review and expansion by Tomislav Meštrović, MD, PhD