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Permanent Contraception

(Sterilization)

By

Frances E. Casey

, MD, MPH, Virginia Commonwealth University Medical Center

Last full review/revision Feb 2022
Click here for Patient Education

In the US, one third of couples attempting to prevent pregnancy, particularly if the woman is > 30, choose permanent contraception with vasectomy or tubal ligation.

Sterilization procedures are very effective; pregnancy rates at 1 year are

  • Vasectomy: 0.15%

  • Fallopian tube permanent contraception procedures: 0.6%

This form of contraception is meant to be and should be assumed to be permanent. If pregnancy is desired, a reversal procedure may be considered, but live birth rates after such procedures are

In women, successful reversal depends on patient age, type of tubal procedure, percentage of tube that remains, amount of scarring in the pelvic area, and fertility test results in the woman and her partner.

General reference

  • 1. Lee R, Li PS, Schlegel PN, Goldstein M: Reassessing reconstruction in the management of obstructive azoospermia: reconstruction or sperm acquisition? Urol Clin North Am 35 (2):289-301, 2008. x. doi: 10.1016/j.ucl.2008.01.005

Male Permanent Contraception (Vasectomy)

For this procedure, the vasa deferentia are cut, and the cut ends are ligated or fulgurated. Vasectomy can be done in about 20 minutes; a local anesthetic is used. Sterility requires about 20 ejaculations after the operation and should be documented by 2 sperm-free ejaculates, usually obtained 3 months after the operation. A back-up contraceptive method should be used until that time.

Mild discomfort for 2 to 3 days after the procedure is common. Taking nonsteroidal anti-inflammatory drugs (NSAIDs) and not attempting ejaculation are recommended during this period.

Complications of vasectomy include

  • Hematoma (≤ 5%)

  • Sperm granulomas (inflammatory responses to sperm leakage)

  • Spontaneous reanastomosis, which usually occurs shortly after the procedure

The cumulative pregnancy rate is 1.1% at 5 years after vasectomy.

Female Permanent Contraception

For permanent contraception in women, the fallopian tubes may be

  • Cut and a segment excised

  • Closed by ligation, fulguration, or various mechanical devices (plastic bands or rings, spring-loaded clips)

  • Completely removed

Pregnancy rates are higher with spring-loaded clips than plastic bands. Procedures that use mechanical devices cause less tissue damage and thus may be more reversible than closure by ligation or fulguration. Complete removal of the fallopian tubes may reduce the risk of ovarian cancer. Postpartum permanent contraception has lower failure rates than interval procedures.

The following surgical approaches may be used:

  • Laparoscopy, usually used for internal procedures (after postpartum period)

  • Minilaparotomy, usually used for postpartum procedures

Tubal ligation can be done during cesarean delivery or 1 to 2 days after vaginal delivery via a small periumbilical incision (minilaparotomy).

Permanent contraception by laparoscopy

Laparoscopic procedures used to provide permanent contraception for women are done as an interval procedure (unrelated to pregnancy), usually at least 6 weeks after delivery and in the operating room; a general anesthetic is used.

The cumulative failure rate of these procedures is about 1.8% at 10 years; however, certain procedures have higher failure rates than others.

Permanent contraception by minilaparotomy

Minilaparotomy is sometimes used instead of laparoscopic procedures, usually when women want permanent contraception soon after delivery of a baby.

Minilaparotomy requires a general, regional, or local anesthetic. It involves a small abdominal incision (about 2.5 to 7.6 cm) and removal of a section of each fallopian tube. Compared with laparoscopy, minilaparotomy causes more pain, and recovery takes slightly longer.

Permanent contraception by hysteroscopy

In the early 2000s, hysteroscopy with placement of coiled microinserts into the fallopian tube was used to provide permanent contraception. As of December 31, 2018, the devices used in this method were removed from the market. Thus, this method is no longer being used.

The coils used for hysteroscopic sterilization consist of an outer layer of a nickel/titanium alloy and an inner layer of stainless steel and polyethylene terephthalate (PET). The PET fibers stimulate an ingrowth reaction that occludes the tubes.

Unintended pregnancy rates are similar with hysteroscopic and laparoscopic permanent contraception. If patients have ongoing pelvic pain or vaginal bleeding, the microinserts may have to be removed, Typically, the microinserts are removed by hysteroscopy, but laparoscopy may be required if part of the microinsert is outside the fallopian tube.

Complications

Complications of permanent contraception in women are uncommon. They include

  • Death: 1 to 2/100,000 women

  • Hemorrhage or intestinal injuries: About 0.5% of women

  • Other complications (eg, failure of tubal occlusion): Up to about 5% of women

  • Ectopic pregnancy: About 30% of pregnancies that occur after tubal occlusion

Complications of permanent contraception by hysteroscopy may also include pelvic pain, abnormal uterine bleeding, and inflammatory disorders.

Key Points

  • Tell patients that vasectomy or tubal ligation should be considered permanent, although a reversal procedure can sometimes restore fertility.

  • For men, the vasa deferentia are cut, then ligated or fulgurated; sterility is confirmed after 2 ejaculations are sperm-free, usually after 3 months.

  • For women, the fallopian tubes are cut or removed; when cut, then part of the tubes is excised, or the tubes are closed by ligation, fulguration, or mechanical devices such as plastic bands or rings; procedures used include laparoscopy and minilaparotomy.

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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