PERMANENT CONTRACEPTION

Bilateral tubal ligation (BTL) is a permanent surgical contraception. It is also called voluntary sterilization. This is surgical procedure whereby the reproductive function of an individual male or female is purposefully and permanently destroyed.

Female permanent contraception is called female sterilization or bilateral tubal ligation. This is defined as the occlusion or division of the fallopian tubes to prevent egg and sperm passage and subsequent fertilization. Female permanent contraception is the world’s most common method of family planning though, men are increasingly taking up vasectomy.

INDICATIONS FOR BILATERAL TUBAL LIGATION

Factors that are associated with increased use of permanent contraception include;

• Increasing age.
• Family planning purposes: This is the principal indication in most of the developing countries.
• Socioeconomic; an individual is adapted to accept the method after having the desired number of children.
• Therapeutic: Medical diseases such as heart disease, diabetes, sickle cell disease, chronic renal disease and hypertension are likely to worsen if repeated pregnancies occur and hence sterilization might be offered as an option.
• Prophylactically: The Society of Gynecologic oncology currently recommends consideration of opportunistic bilateral salpingectomy (excision of the fallopian tubes) as a preventive measure against serous ovarian and peritoneal cancers among women who are at average risk of ovarian cancer and are undergoing other pelvic surgery.

CONTRA-INDICATION TO BILATERAL TUBAL LIGATION

Patient ambivalence regarding sterilization is an absolute contraindication. Even though surgically reversing the tubal occlusion at a later date or becoming pregnant through in vitro fertilization(IVF) is technically feasible.

WHAT TO EXPECT AT CONSULTATION WITH YOUR DOCTOR?

During counselling when permanent contraception is considered, this will involve a shared decision making with your doctor. Counselling regarding alternative methods of contraception, their risks and benefits to permanent contraception will be discussed. The risks and benefits of the procedure will also be discussed and your expectations and concerns established and addressed.

Bilateral tubal ligation does not interfere with menses; as you will continue to see your menses and it does not affect your sexual life. Your doctor will tell you that it’s one of the best method of contraception but it can also fail just like other methods, but it is associated with very low failure rate; <1 in 100 women who will have it per year. Your doctor will let you know that bilateral tubal ligation is also associated with regret and the risk factors for regret will be assessed and discussed.

RISK FACTORS FOR REGRET AFTER BILATERAL TUBAL LIGATION

 It has been reported that 7 in 100 women that had tubal ligation had regrets by the 5^th year. The risk factors for regret are;

• young age
• Single marital status
• Loss of a child
• Divorce
• Women who undergo an immediate postpartum permanent contraception; you should note that your doctor will not accept your request for a permanent contraception when that is made while in labour. Discussion concerning bilateral tubal ligation are usually made during the antenatal care period. In African, you will be asked to seek your partner’s consent.

WHEN IS BILATERAL TUBAL LIGATION DONE?

The decisions regarding timing (interval, postpartum or post-abortion) and surgical approach are made based on patient preference, recent pregnancy, surgical history, and the presence of other medical conditions. Interval permanent contraception is any permanent contraception procedure performed after six weeks of delivery.

Post-abortion permanent contraception is typically performed via laparoscopy immediately following uterine evacuation and postpartum permanent contraception is performed within six weeks of delivery. For an interval sterilization, a woman may already be pregnant when the procedure is performed. This is avoided by scheduling surgery immediately after the menses and by doing a pregnancy test before the operation.

SURGICAL APPROACH FOR BILATERAL TUBAL LIGATION

Surgical approaches for female sterilization include;

• Laparoscopy; in rich resource setting, laparoscopy is used most commonly for interval procedures. Approach here is through small incisions on the abdomen while you are asleep under anaesthesia. A video assisted instrument is passed into the pelvic cavity through this incision to identify and occlude the fallopian tube. It is associated with less pain after the procedure and good cosmetic.
• Hysteroscopy; here the approach is through the vaginal using a video assisted instrument to introduce the material or device that will cause occlusion of the fallopian tube
• Laparotomy; this is done during caesarean section
• Mini-laparotomy; is the most common approach worldwide. The incision is at same location like that of the laparotomy but smaller about 5cm.

COMPLICATIONS OF TUBAL STERILIZATION

Although hysteroscopic sterilization can avoid the risks of a general anaesthesia, laparoscopy and abdominal scars. Potential complications and adverse events include tubal perforation, infection, device migration, device expulsion and vasovagal pain and chronic pelvic pain. Risks of laparoscopic sterilization include failure, risk of injuries to the bowel, bladder and blood vessels. Other complications of tubal ligation are haemorrhage and ectopic pregnancy when it fails.