Tubal Ligation: Some Questions and Answers
Few Choices are more serious than that of a woman to prevent pregnancy by surgical sterilization. Every year hundreds of thousands of women make that choice. They may be driven by fear of sickness or death from the Pill or IUD and their abortion-causing effects, fear of unplanned pregnancies resulting from the less effective barrier methods, and sometimes fear of exercising sexual self-control.
Many couples turn to surgical sterilization out of desperation, but later come to regard this step as drastic and unwise especially when they learn about the highly effective modern method of natural family planning known as the Sympto-Thermal Method.
A tubal ligation is a surgical operation performed to make a woman sexually sterile. There are two common methods of tubal ligation; minilaparotomy and laparoscopy. A minilaparotomy involves making a small incision in the abdomen and locating the fallopian tubes, which conduct the eggs from the ovaries to the uterus. After the tubes are found and drawn outside the body through the incision, a portion of each tube is removed and the ends are tied.
In laparoscopy the woman’s abdomen is first inflated with carbon dioxide or nitrous oxide gas, creating a gap between the bowel and the abdomen. A fiberoptic light is inserted (by puncturing the abdominal wall) and an instrument either coagulates the tubes with an electric current or places a band or clip on the tubes.
No. The only 100% effective sterilization surgeries are male castration (removal of the testicles) and female castration (removal of the ovaries); these surgeries are simply not performed for birth control purposes.
Tubal ligation has a failure rate of .1% (one-tenth of one percent)1 This is about the same overall failure rate as vasectomy. Pregnancies can occur due to surgical error, equipment failure, or the natural processes in which the body reestablishes a connection from the uterus to the abdominal cavity.2
Yes and no. Reversal surgery can sometimes be done, but it does not necessarily restore fertility. Success rates for the reversal of female sterilization procedures can be misleading since up to 70% of women requesting reversals are not accepted for surgery because too much damage has been done to the fallopian tubes or other reproductive organs.3 Therefore, "women must consider any sterilization technique as permanent."4
"Depending on the sterilization technique used, between 800 and 2,000 women per 100,000 can expect a major complication at the time of operation," according to the Alan Guttmacher Institute.5
Minilaparotomy patients may suffer from such complications as infection, injury to the bladder or bleeding from a major blood vessel, and burning of the bowel or other structures. There also can be anesthesia complications.6
Laparoscopy has serious complications such as perforation of the bowel leading to massive infection of the abdominal cavity, complications from anesthesia, improper clearance of the windpipe during the operation, even pulmonary embolism.7 Dr. H.P. Dunn noted, "Every operation carries the risk of hemorrhage or infection... Some patients have died from cardiac failure during the inflation procedure. Others have suffered wounds of the bowel, bladder, and large blood vessels. Even intraperitoneal explosions have occurred." 8
Apart from these immediate complications of surgery post-tubal problems are so frequent they are now called "post tubal ligation syndrome." A review of the literature on post-tubal ligation problems by Drs. Joel Hargrove and Guy Abraham revealed an incidence of long-term complications in as many as 22 to 37% of sterilized women.9
Dr. Vicki Hufnagel, a surgeon who specializes in restoring women’s reproductive organs, has written "Many post-tubal patients who come to my office seeking relief complain bitterly if more severe cramps, heavier. longer periods, dysfunctional uterine bleeding, pain with intercourse, and pelvic pain or pressure."10
A study in Britain followed 374 post-tubal patients and found that 43% had subsequent gynecological treatment for such conditions as heavy menstrual bleeding, menstrual disturbances requiring hormonal treatments, cervical erosion, ovarian tumors, and recanalization of the fallopian tubes requiring a second operation.11
Another British study of tubal ligation found a 40% increase in menstrual blood loss; 26% of the group experienced increased menstrual pain. Women who had used the Pill before their tubal ligation reported more of these complains than other patients.12
A study by James G. Tappan found a 40.7% incidence of menorrhagia and suggested that cystic degeneration of the ovary may result from interruption of blood flow from the uterine artery.13 A longitudinal study of over 8,000 women five years after their tubal ligations found 49% of them suffered heavy periods and 35% reported an increase of severe menstrual cramping.14 The risk of cervical cancer among a study of 489 post-tubal women was 3.5 times the normal rate.15
As mentioned previously, many couples attempt to have sterilization reversed, though fewer than half of reversals are functionally successful.16 Women who do achieve pregnancy after the reversal of tubal ligation face anywhere from a 4% to 64% increased risk of tubal pregnancy, a life-threatening and psychologically wrenching experience. The rate of risk depended on the procedure used.17
Furthermore, it is difficult to assess the health risks involved when women voluntarily forego the benefits of future pregnancies. Greater risks of ovarian cancer18 and endometrial cancer19 are associated with having few or no children.
There is an increased incidence of women with tubal ligations undergoing subsequent hysterectomy due to severe menstrual problems-18.7% among one group of 374 patients.20 In a study of long-term risk, women aged 20 to 29 years who had tubal ligations were found to be 3.4 times as likely to have a subsequent hysterectomy.21
Tubal ligation is also a risk factor for Premenstrual Syndrome (PMS). Katarina Dalton, M.D., found of the world’s first PMS clinic stated, "Recently, it has been recognized that Premenstrual Syndrome often increases in intensity following tubal ligation...After women had the simple operation to block their fallopian tubes, they subsequently produced less progesterone from their ovaries ."22 This has been confirmed by other research23
The ovaries function poorly as a result of the disruption of blood supply to them; elevated levels of estrogen and inadequate progesterone may explain the heavier bleeding and cramping that often follow female sterilization.24
Because tubal ligations are frequently done after the delivery of a child , conditions such as ordinary postpartum depression may mask the connection with PMS in short term studies. Progesterone levels before and after tubal ligation are an area yet to be studied.25
Weight gain following tubal ligation is commonly reported but it also has not been the subject of research.
Although each year approximately a million Americans choose sterilization for birth control purposes,26 long-range studies of the psychological effects of sterilization are difficult to find. However, Premenstrual Syndrome is well-known for its mentally disorienting and emotionally devastating effects. It has even been used successfully as an "insanity" defense in criminal trials.
When a woman takes such an irrevocable course of action, it is psychologically difficult to admit that a mistake has been made. This explains why patients who experience difficulties with sterilization still respond in surveys that they are "satisfied" with the procedure. "The need to convince ourselves is served by convincing others," noted one researcher.27
There is little research on the social consequences of sterilization.
Minimum age and spousal consent requirements for sterilization have been reduced in many states, which may cause stress in marriages, especially when a couple reconsiders this permanent decision made earlier in their married life. Two-thirds of sterilization’s are tubal ligations, in contrast to the early 1970s when nearly 60% of such operations were vasectomies.28
The ratio of male to female sterilization may look like just another boring statistic, but behind every statistic is a human story. A dramatic, often non-verbal tug-of-war over whose fertility is to be sacrificed hides behind this sociological statistic. Now that vasectomy has been associated in the media with a higher risk of prostate cancer, the pressure on women to bear the sole burden of sterilization may increase.
Regrets over this decision, made under stressful circumstances, may affect marriage adversely. Some of the most heartbreaking letters received by the Couple to Couple League come from couples who have deep sorrow and bitterness about a sterilization operation.
Another distressing social consequence comes from the very nature of sexual sterilization: the acceptance of the idea that an essential part of the body can be disconnected like a machine. This has grave implications. Cats and dogs are spayed for the convenience of their masters — but who are the "masters" in the human social order? Contemporary opinion holds that your body belongs to you. However, the traditional belief is that we are stewards of our bodies, gifts from God that should never be mutilated. Such a belief places a check both on the power of state, and on the self-will of the individual.
Yes. Perhaps the greatest social danger from "voluntary" sterilization is hat it is only a half step away from forced sterilization. If people reject the reality that sterilization is a serious evil, accepting it as a "morally neutral act", the way is paved for coerced sterlization.29 In any functional social order, citizens may be morally compelled to do certain things, but they may not morally be forced to perform evil actions nor forced to consent to them. For example, traffic laws force us to limit our speed, but there is nothing inherently evil in driving slower. Such legitimate laws are morally justified forms of coercion.
However, sterilization attacks the physical integrity of the human person. While this may be justified as a punishment for crime, the evil of sterilization should not be forced on anyone as a matter of social policy. The Nazis held differently: those considered "unfit" by Nazi standards lost their right to reproduce. Indira Gandhi launched a massive coerced sterilization campaign that led to her electoral defeat. In the United States , Margaret Sanger, foundress of Planned Parenthood, advocated sterilization of the poor,30 and there have been other attempts at forced sterilization for population control.31
Before 1930, no Christian Church accepted sterilization or any form of contraception as morally acceptable. The Catholic Church and some Protestant Churches still teach that deliberate sterilization is an immoral form of birth control. "Equally to be excluded [as morally permissible], as the teaching authority of the Church has frequently declared, is direct sterilization, whether perpetual or temporary, whether of the man or of the woman" (Humanae Vitae, 14).32
Yes. Even for the couple who have a most serious reason to avoid pregnancy, the Sympto-Thermal Method of Natural Family Planning (NFP) offers a realistic and moral alternative. No methods are 100% effective (except total abstinence or castration), but studies of Sympto-Thermal Methods have shown remarkably high effectiveness rates.33 One study of a temperature-only form of NFP showed an unplanned pregnancy rate below that for vasectomy and tubal ligation sterilization.34
Contact The Couple to Couple League either in your own area or at its national office in Cincinnati , Ohio .
References
1. Robert A. Hatcher, et al., Contraceptive Technology (New York: Irvington, 1990) 414.
2. Ibid, 404.
3. Hatcher, 416.
4. A. Henry., W. Rinehart and P T Piotrow, '"Reversing female sterilization," Population Reports, 1980; Series C(8):97-123; see also A.M. Siegler, J. Hulka, and A. Peretz, "Reversibility of female sterilization," Fertility and Sterility (1985) 43:499-510.
5. Susan Harlap, Kathryn Kost, and Jacqueline Darroch Forrest, Preventing Pregnancy, Protecting Health: A New Look at Birth Control Choices in the United States (New York: Alan Guttmacher Institute, 1991) 92.
6 Ibid, 395.
7. D.B. Scott and D. G. Julian. "Observations on cardiac arrhythmias during laparoscopy," British Medical Journal 1:411.
8. H.P. Dunn, "Unexpected sequelae of sterilization," International Review of Natural Family Planning, 1:4 (Winter 1977) 318.
9. J. Hargrove and G. Abraham, "Endocrine profile of patients with post-tubal ligation syndrome," Journal of Reproductive Medicine, 26-7 (July 1981) 359-362.
10. M. V. Hufnagel, No More Hysterectomies (New York: Penguin, 1989) 228.
11. M J Muldoon, "Gynaecological illness after sterilization," British Medical Journal (Jan. 8, 1972) 84-85, Table III.
12. S. Lawson, R. A. Cole, and A. A. Templeton, "The effect of laparoscopic sterilization by diathermy or silastic bands on post-operative pain, menstrual symptoms and sexuality," British Journal of Obstetrics and Gynecology, 86:659-663. This updates J. R. Neil’s follow-up of 454 women in 1975 which found an incidence of between 22% to 39% of the study experiencing menstrual problems after their tubals. J. R. Neil, et al., "Late complications of sterilization by laparoscopy and tubal ligation: a controlled study," The Lancet (Oct. 11, 1975) 6999-700.
13. J. G. Tappan, American Journal of Obstetrics and Gynecology 115:8 (Apr. 15, 1973) 1056.
14. L. W. Wilcox et al "Menstrual function after tubal sterilization," American Journal of Epidemiology, 135:1368-1381.
15. Ibid.
16. For men the rate is around 50%, for women slightly better, although up to 70% of women requesting reversals are not accepted for the surgery because of irreversible damages. A.M. Siegler, et al, "Reversibility of female sterilization," Fertility and Sterility (1985) 43:499-510.
17. L.Liskin, W. Rinehart, R. Blackburn, and A. H. Rutledge, "Minilaparotomy and laparoscopy: safe, effective and widely used," Population Reports, 1985; Series C (9):125-167.
18. M. Booth, V. Beral, and P. Smith, "Risk factors for ovarian cancer: a case control study." British Journal of Cancer (1989) 60:592; D.W. Cramer, "Factors affecting the association of oral contraceptives and ovarian cancer," New England Journal of Medicine (1982) 307-1047.
19. F. DeWard "Uterine Corpus," Chapter 52 in Cancer Epidemiology and Prevention (Philadelphia: W. B. Saunders, 1982), D. Schottenfeld, J.F. Fraumeni, eds.
20. Muldoon, Table II,
21. A. Stergachis, et al, "Tubal sterilization and the long-term risk of hysterectomy," Journal of the American Medical Association (Dec. 12,1990) 264-2893-2899.
22. K. Dalton, Once a Month (Claremont, CA: Hunter House, 1990) 33.
23. Hargrove and Abraham, 359-352.
24. F. Alvarez-Sanchez, et al., "Pituitary-ovarian function after tubal ligation," Fertility and Sterility (Nov., 1981) 36:606-609; J. Cattanach, "Oestrogen deficiency after tubal ligation," The Lancet (Apr. 13, 1985) 847-849; M. El-Minawi et al., "Pelvic venous changes after tubal sterilization," Journal of Reproductive Medicine, 28:641-648.
25. "No studies have evaluated presterilization and poststerilization levels (of progesterone)." Hatcher p.403.
26. Association for Voluntary Surgical Contraception News 1989;
27 (July)1. 27. H. Wolfers, "Psychological aspects of vasectomy." British Medical Journal(1970) 4:297.
28. Association for Voluntary Sterilization figures cited in Roberts, p.35.
29. "Let it be considered also that a dangerous weapon would thus be placed in the hands of those public authorities who take no heed of moral exigencies. Who could blame a government for applying to the solution of the problems of the community those means acknowledged to be licit for married couples in the solution of a family problem?" Pope Paul VI, Encyclical letter Humanae Vitae, dated July 25, 1968, 17.
30. Margaret Sanger, Pivot of Civilization (New York: Brentano’s, 1922) 124-145. Sanger expresses an especially strong paranoia that irresponsibly copulating "subhumans" will overpopulate the earth and contaminate the gene pool.
31. Sterilization as a tool of the state has a long history in America . In the mid-1980s castrations was used on the "feeble-minded" in Kansas . In 1899 a 19 year old was castrated at the Indian Reformatory because of his "addiction" to masturbation. In 1907 Indiana commenced sterilizing criminal and "unfit" elements in the state. Fifteen states enacted similar laws between 1907 and 1917. The eugenics movement touted the social benefits of involuntary sterilization into the 1930s. In 1974 two Alabama sisters, age 12 and 14, were sterilized without their consent at a Montgomery birth control clinic.
32. Humanae Vitae, 14.
33. R. E. J. Ryder, "'Natural family planning': effective birth control supported by the Catholic Church," British Medical Journal (Sept. 18,1993) 307:723-726. This article compared studies from around the world indicating that modern inexpensive NFP methods, used by well-motivated couples, are as effective as the Pill in regulating births.
34. B. Vincent, et al., Methode Thermique a et Contraception: Approaches medical et psychologique (Paris: Masson, 1967), 52-73.
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