Tubal Ligation

What is tubal ligation?

Tubal ligation, also known as female sterilisation, is a permanent method of birth control. In tubal ligation, both the fallopian tubes are removed or cut and tied with special thread, or closed shut with bands or clips, or sealed with an electric current. It will prevent the sperm from reaching the egg, and thus preventing pregnancy.

Note:  Bilateral tubal ligation (BTL) and tubal ligation both refer to the same procedures, with the term BTL commonly used in hospital settings. Tubal ligation can be either unilateral or bilateral. However, for effective prevention of pregnancy, it is important for both fallopian tubes to be blocked or sealed.

Bilateral tubal ligation procedure: How is it done?

BTL can be performed through two methods: 

1. Minilaparotomy: This involves a small (usually less than 5 cm) suprapubic incision into the pelvic cavity. 

2. Laparoscopy: This technique involves performing the operation in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera known as a laparoscope.

Steps:

1. Preparation:

   • The patient is typically asked to fast for a certain period before the surgery.

   • A thorough medical history and physical examination are conducted.

2. Anesthesia:

   • The patient is administered anesthesia to ensure they are comfortable and pain-free during the procedure.

3. Incision or access:

   • A small incision is made near the navel (belly button) or in the lower abdomen.

4. Access to fallopian tubes:

   • The surgeon gains access to the fallopian tubes by lifting the abdominal wall and identifying the tubes.

5. Blocking, sealing, or cutting the tubes:

   • Different techniques may be used to block or seal the fallopian tubes, such as clips, rings, burning (cauterisation), or cutting and tying.

6. Closure of incision:

   • The incision is closed using stitches, staples, or adhesive strips.

7. Recovery:

   • The patient is monitored in a recovery area until they wake up from anesthesia.

   • Pain medication may be prescribed to manage postoperative discomfort.

8. Postoperative care:

   • Patients are advised to take it easy and avoid heavy lifting or strenuous activities for a certain period.

   • Follow-up appointments are scheduled to monitor recovery and ensure there are no complications.

BTL is considered a relatively minor surgery, and many women can typically return home on the same day of the procedure.

How effective is BTL in preventing pregnancy?

Laparoscopic sterilisation is more than 99% effective at preventing pregnancy.

Who needs BTL?

BTL is suitable for:

• Women who want a permanent method of contraception.

• Women at risk of medical complications from future pregnancies, for instance, women with conditions such as high-risk heart disease.

Who is not suitable for BTL?

BTL should not be considered by the following women who:

• are uncertain or have mixed feelings about the procedure

• are younger than 30 years, as they are statistically more likely to experience regret following the procedure compared to older women

• are incapable of making a medical decision, 

• are diagnosed with gynecological malignancies, as sterilisation may not be the primary concern in the presence of such medical conditions.

• desire for future childbearing

What are the pros and cons of bilateral tubal ligation (BTL)?

Pros of BTL

• High effectiveness: BTL is more than 99% effective at preventing pregnancy, providing a reliable form of contraception.

• Hormone levels remain unaffected: It does not impact hormone levels, thus it will not interfere with your menstruation cycle.

• Immediate effectiveness: BTL is typically effective immediately, although it's advisable to use contraception until the next menstrual cycle.

• No impact on sex drive: It does not affect sex drive or interfere with sexual function.

Cons of BTL

• No protection against STIs: BTL does not protect against STIs, emphasising the importance of using barrier methods (eg: condoms) if protection against STDs is needed.

• Irreversible nature: The procedure is basically irreversible, making it crucial for individuals to be certain about their decision.

• Rare but possible failure: BTL can fail, although it is rare, and if pregnancy occurs after the procedure, there’s an increased risk of ectopic pregnancy.

How much BTL cost in Singapore?

The cost of BTL in Singapore depends on the type of procedure, the type hospital/clinic you choose (public or private) and the doctor’s fees. In the Ministry of Health's fee benchmarks for 2023, the combined fees for the surgeon and anaesthetist range from around $1900 to $3100.

What are the side effects of having a bilateral tubal ligation (BTL)?

Mortality is low and about 0.01% to 0.02% and mostly related to general anesthesia. The risks of the surgery includes:

• Risk of injury: Potential risks include injury to the bowel, bladder, or blood vessels during the surgery.

• Failure to achieve sterility: While rare, there is a possibility of the procedure not achieving the intended sterility.

• Pain: Post-operative pain is a common concern, though it is typically managed with appropriate pain relief measures.

• Infection: As with any surgical procedure, there is a risk of infection, which is typically minimised through sterile techniques.

FAQ

What are the side effects of bilateral tubal ligation (BTL) after c-section?

There are no differences in the side effects between undergoing bilateral tubal ligation (BTL) independently and having BTL performed after c-section.

Is bilateral tubal ligation (BTL) 100% effective?

BTL is not 100% effective at preventing pregnancy. In fact, there is no any single contraception method that is 100% effective. Although BTL is considered a permanent contraception, pregnancy can occur in 1 in 200.

What are some alternatives to bilateral tubal ligation (BTL)?

Long-acting reversible contraception such as the intrauterine device (IUD) or birth control implant (Implanon), are about as effective at preventing pregnancy as BTL and they can last for several years. They can be removed anytime if you want to become pregnant. Another alternative is vasectomy, a method of male sterilisation for partner.

Vasectomy vs tubal ligation: Is it better to get a vasectomy or tubes tied?

The decision between getting a vasectomy or having tubal ligation (tubes tied) is highly personal and depends on various factors. There isn't a one-size-fits-all answer, as what may be "better" for one person or couple might not be the same for another.

What to expect after bilateral tubal ligation (BTL)?

After surgery, you will be observed for some time to ensure there are no problems or complications post-operatively. Most women can go home on the same day after the procedure. You will need someone to take you home. You may feel some discomfort or have other symptoms that last a few days:

• Dizziness and nausea

• Abdominal cramps

• Gassy or bloated feeling

• Sore throat (from the breathing tube if general anesthesia was used)

Most women return to their normal routines within one week of surgery.

Does bilateral tubal ligation (BTL) stop periods?

No, BTL will not affect your hormone levels, thus will not interfere with your menstruation.

Bilateral tubal ligation (BTL) reversal: What if I decide I want to get pregnant after I have the procedure?

If you opt for BTL but later change your mind after the operation, attempting to reverse the procedure may not always be successful. Even if a reversal is performed, achieving pregnancy may remain challenging for many women. Additionally, in cases of post-BTL pregnancies, there is an increased risk of ectopic pregnancy, further emphasising the importance of careful consideration and consultation before choosing this permanent contraceptive method.

References

1. American College of Obstetricians and Gynecologists 2022

2. Date SV, Rokade J, Mule V, Dandapannavar S. Female sterilization failure: Review over a decade and its clinicopathological correlation. Int J Appl Basic Med Res. 2014 Jul;4(2):81-5. doi: 10.4103/2229-516X.136781. PMID: 25143881; PMCID: PMC4137647.

3. Marino S, Canela CD, Nama N. Tubal Sterilization. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan.