INTRODUCTION — Female permanent contraception (also referred to as sterilization, tubal ligation, and partial or complete salpingectomy) can be performed using several different procedures and techniques that prevent pregnancy by occluding or removing the fallopian tubes.
Female permanent contraception may be performed immediately after childbirth (postpartum permanent contraception) or at a time unrelated to a pregnancy (interval permanent contraception). In the United States, it is estimated that over 50 percent of permanent contraception procedures performed each year are in the postpartum period . Most postpartum permanent contraception procedures are performed via laparotomy, either at the time of cesarean birth or via mini-laparotomy following vaginal birth. Most interval permanent contraception procedures are performed via laparoscopy.
This topic will focus on the different procedures used to perform postpartum permanent contraception. An overview of general principles of female permanent contraception and laparoscopic permanent contraception is discussed elsewhere.
PREOPERATIVE PLANNING — The only indication for permanent contraception is the patient's preference to have a permanent method of contraception for pregnancy prevention. The choice is made by the patient, but the decision requires thorough preoperative counseling and planning. (See "Overview of female permanent contraception", section on 'Counseling and informed consent'.)
Preoperative evaluation and preparation — Preoperative evaluation and preparation items for postpartum permanent contraception are listed briefly here and discussed in more detail separately:
●Counseling about alternatives to permanent contraception, including long-acting reversible contraception and vasectomy. (See "Overview of female permanent contraception", section on 'Counseling and informed consent' and "Postpartum contraception: Counseling and methods", section on 'Methods'.)
●Counseling about, and assessing risk factors for, tubal regret. (See "Overview of female permanent contraception", section on 'Risk factors for regret'.)
●Assessment of surgical risk and medical comorbidities with appropriate preoperative consultation and testing. It is possible, but more challenging, to perform a mini-laparotomy on patients with obesity , prior abdominoplasty, and other prior abdominal and pelvic surgery. These technical factors should be considered when advising patients prenatally about their contraceptive options. In addition, it is prudent to delay the procedure until peripartum complications that increase maternal surgical risk (eg, postpartum hemorrhage, severe preeclampsia, peripartum infection) have resolved. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)
●Antibiotic prophylaxis is typically not recommended for tubal occlusion procedures but may have been given for obstetric indications (eg, chorioamnionitis, cesarean birth prophylaxis).
●Pneumatic compression boots are generally advised for venous thromboembolism (VTE) prophylaxis at cesarean birth. Most clinicians do not use thromboprophylaxis for tubal permanent contraception following vaginal birth; however, the need for thromboprophylaxis should be assessed for those at elevated risk of VTE (table 1). (See "Cesarean birth: Preoperative planning and patient preparation", section on 'Thromboembolism prophylaxis' and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients".)
Timing — For patients having a cesarean birth, permanent contraception is performed concomitant with the delivery.
Permanent contraception following vaginal birth is generally performed within the first 24 to 48 hours after delivery when the uterine fundus is readily accessible at the level of the umbilicus. The 24- to 48-hour time period is preferred for several reasons:
●The procedure is performed before significant uterine involution has occurred. This allows use of an infraumbilical incision, which has favorable cosmetic results.
●If the patient had epidural anesthesia for delivery and a postpartum tubal ligation is planned, the epidural catheter can often be left in place and used to administer anesthesia for the permanent contraception procedure if felt to be safe and effective by the anesthesiologist.
●The patient cannot eat or drink for a period of hours before the procedure, so if the procedure is delayed, this can be difficult for the patient.
If the procedure cannot be performed at the time of delivery, it can often be done before the mother is discharged as long as the uterus is accessible from the infraumbilical incision. There are no data supporting a specific number of days postpartum after which the procedure should not be performed.
PROCEDURE — The type of procedure for postpartum permanent contraception depends upon the mode of delivery.
Following vaginal birth — Surgical permanent contraception after vaginal birth is most commonly accomplished through an infraumbilical mini-laparotomy. This is minimally invasive and results in favorable cosmetic results.
The patient is administered regional anesthesia (if not already in place for delivery) or, infrequently, general anesthesia. The bladder should be emptied. A 2 to 3 cm transverse or semicircular incision (mini-laparotomy) is created in the infraumbilical fold at the level of the uterine fundus (figure 1). Once the peritoneum is identified and opened, the surgeon's finger is used to palpate the uterine fundus and, sweeping laterally toward the adnexa, is gently hooked under the fallopian tube to bring it toward the midline incision. Maneuvers that can assist in bringing the adnexa toward midline include tilting the operative bed toward the operating surgeon and directing the assistant to use external pressure on the enlarged postpartum uterus for stabilization. Small, right angle retractors placed into the peritoneal cavity can assist in identification of the fallopian tubes, or a small, self-retaining, flexible, circular retractor can be placed, but the right angle retractors allow more flexible access to the tubes.
Once the tube is identified, it is grasped with a Babcock clamp and elevated out of the abdomen. At this point, it is essential to follow the fallopian tube out to its fimbriated end for confirmation, using two Babcock clamps to march along the length of the tube. Tubal permanent contraception failure can result from resection of the wrong structure, typically the round ligament or a fold of the broad ligament . Correct identification of the fallopian tubes may be more difficult after prior pelvic surgery or inflammation, endometriosis, or uterine anomalies.
Next, the surgeon should identify a 2 cm segment of tube in the mid-isthmus, using transillumination to identify an avascular space in the mesosalpinx beneath the area planned for resection. The Babcock clamp elevates this portion of the tube, and one of the methods of partial salpingectomy is performed (see 'Partial salpingectomy' below). Care should be taken to remove a segment in the midline of the fallopian tube as resection of distal segments toward the fimbria may lead to risk of tubal recanalization and higher failure rates . The contralateral fallopian tube is then identified and resected using the same technique. Both segments of tube are typically sent to pathology to confirm that a complete cross-section of the tube was achieved.
Postpartum laparoscopic permanent contraception has been reported; however, it has not gained widespread acceptance, likely because of the general ease of mini-laparotomy in the postpartum setting. The enlarged postpartum uterus can increase the risk of injury during laparoscopic trochar placement and can obstruct the view of the laparoscopic camera. Additionally, the equipment for laparoscopy is often not available on a labor and delivery unit .
Following cesarean birth — Surgical permanent contraception adds only a few minutes to the cesarean birth procedure, and no additional incisions are needed. At the time of cesarean birth, tubal permanent contraception is performed after closure of the hysterotomy. If the uterus is externalized, the fallopian tubes are easily identified; if the uterus is left in situ, retractors are needed, along with lateral displacement of the uterus, in order to visualize one fallopian tube at a time.
The same technique described above for mini-laparotomy after vaginal birth should be followed to grasp and identify the tubal segment planned for resection. (See 'Following vaginal birth' above.)
Tubal occlusion methods
Our approach — There are a variety of options of tubal occlusion methods for postpartum permanent contraception, and the decision is ultimately based on patient and surgeon preference. In our practice, we prefer partial salpingectomy as it is effective, time-efficient, and with less potential for serious bleeding than complete salpingectomy.
Ultimately, the specific method of partial salpingectomy employed for postpartum permanent contraception is based on the surgeon's experience and preference, given that comparative trials of the different techniques for partial salpingectomy have not been performed. The only exception is the titanium clip, which is not recommended postpartum because of high failure rates, probably because it is inadequate to contain the enlarged vascular oviducts of term pregnancies. (See 'Titanium clip' below.)
Partial salpingectomy — The surgical techniques for partial salpingectomy commonly involve resection of a tubal segment at least 2 cm in length. Removal of a segment of tube results in eventual scarring and closure of the tubal remnants. Care should be taken to ensure that, when placing the tube (or uterus, if externalized at cesarean birth) back into the abdominal cavity, the sutures securing the tubal stumps are not displaced, which might result in excess bleeding or even need for reoperation. As the tubal stumps heal, the suture absorbs, and the ends fall apart (figure 2). If bleeding is present, most surgeons use electrocautery sparingly so that the tubes remain separated upon healing.
The tubal segments removed should be sent for pathology evaluation, separately labeled as "left fallopian tube" and "right fallopian tube," for confirmation of excision of the full thickness of the tube.
Parkland technique — The steps of the Parkland tubal permanent contraception technique are as follows (figure 3):
●An opening is created sharply in an avascular portion of the mesosalpinx. Two free ties of absorbable suture (0 chromic or plain gut) are passed through the opening, and one strand is used to ligate the proximal end of the tube and the other to ligate the distal end of the tube. The ends can be doubly ligated to ensure hemostasis.
●A 2 cm segment is sharply excised between the sutures. The ends are immediately separated.
●The mid-isthmic portion of the tube is elevated and folded at the midpoint, bringing the distal and proximal ends of the tube together. The tube is ligated by tying one or two rapidly absorbing sutures around the entire double thickness of the tube. Pomeroy originally described use of chromic ties; however, many surgeons now use a "modified" Pomeroy technique and employ plain gut suture because it is more rapidly absorbed, allowing the tubal stumps to fall away from one another sooner .
●The folded portion of the tube is sharply excised. Care should be taken to remove at least a 2 cm segment of tube. There should be an adequate margin between the suture and the cut end to prevent the cut ends of the tube from slipping out of the suture.
●The cut ends of the tube are inspected to visualize the tubal lumen; this confirms resection of a full thickness of the tube.
Less common partial salpingectomy methods
Irving technique and Uchida technique — The Irving and Uchida techniques both require more extensive dissection and operative time and have a greater risk of bleeding than partial salpingectomy; they are not commonly used in the United States . Use of the Irving or Uchida techniques is feasible at the time of cesarean birth but would be more difficult to accomplish through a mini-laparotomy incision.
Both the Uchida and Irving techniques involve burying a tubal stump in a nearby structure. They were developed to minimize risk of tuboperitoneal fistula formation and contraceptive failure . These techniques are believed to be more effective than the Pomeroy or Parkland techniques but have not been directly compared.
In our practice, we have used these techniques following failed tubal permanent contraception procedures. In China, the Uchida technique is widely used as an interval method of permanent contraception via laparotomy and is reported to have comparable efficacy to permanent contraception via use of a "silver clip" .
In brief, the techniques involve ligation and excision of the midportion of the tube followed by:
●Irving technique – The proximal tubal stump is then inserted into an incision in the myometrium and sutured securely to bury the stump within the myometrium (figure 6).
●Uchida method – The uterotubal serosa is hydrodissected, the proximal tubal stump is pulled into the mesosalpinx, and the peritoneum is closed over the proximal cut end of the tube leaving the distal stump outside the mesosalpinx (figure 7).
Distal fimbriectomy — Distal fimbriectomy alone is not recommended as a method of permanent contraception because higher failure rates were reported historically, presumably related to risk of patent residual tubal lumens .
Complete salpingectomy — The increased interest in complete salpingectomy for permanent contraception is based upon a potential beneficial effect of salpingectomy on ovarian cancer risk. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction", section on 'Ovarian cancer risk reduction'.)
When reviewing informed consent with patients for postpartum tubal permanent contraception, it is reasonable to discuss complete salpingectomy as an available and usually feasible option. Surgeons should offer partial or complete salpingectomy based on their experience and preference as there is no routinely recommended approach at this time.
●At time of cesarean birth – Data regarding complete salpingectomy at time of cesarean birth are conflicting. In a meta-analysis including four randomized trials and 186 patients undergoing either complete or partial salpingectomy at the time of cesarean birth, total operative time was similar between groups with an increase of approximately seven minutes in the complete salpingectomy group (95% CI -8.5 to 22.7 minutes; three studies) . Blood loss, complication rates, adverse outcomes, ovarian reserve (measured by anti-müllerian hormone; one study), and risk of postoperative pregnancy (one study) were also similar for both procedures. A limitation of this meta-analysis is the relatively small number of participants and the small number of adverse events overall. By contrast, in a retrospective study including over 300,000 patients undergoing sterilization at the time of cesarean birth for whom perioperative outcome measures were available, complete compared with partial salpingectomy was associated with higher rates of hemorrhage (odds ratio [OR] 1.16) and unplanned oophorectomy (OR 1.75); the risk of blood transfusion was similar between groups . However, these odds were higher in those requiring cesarean hysterectomy (hemorrhage: OR 1.25, oophorectomy: OR 2.02, blood product transfusion: OR 1.16); the risk of undergoing cesarean hysterectomy was over twofold greater in the complete salpingectomy group (OR 2.28).
●After vaginal birth – Operative time appears to be similar among permanent contraception procedures when performed after vaginal birth. In a retrospective study including over 300 patients undergoing complete or partial salpingectomy via an infraumbilical mini-laparotomy incision after vaginal birth, operative time was similar between groups (average decrease of approximately four minutes in the complete salpingectomy group); a bipolar electrocautery device rather than suture ligation was used in the majority (94 percent) of patients undergoing complete salpingectomy . Perioperative complications were similar between groups but the study was underpowered to detect such an effect.
Technique — With complete salpingectomy, the tube is identified out to its fimbriated end and freed from any adhesions. A disposable handheld bipolar electrocautery device then divides the tube from the mesosalpinx. Use of a disposable instrument, though higher cost, may prevent bleeding complications from the enlarged postpartum vasculature and decrease operative time, and, therefore, we prefer this method if available.
Alternatively, the mesosalpinx can be divided using clamps and suture ligation with careful technique to secure the vascular supply in this area . One method is to create a window in an avascular space in the lateral aspect of the mesosalpinx. Next, a Kelly clamp is placed from lateral to medial across the mesosalpinx before sharply dividing it and securing the pedicle with a free tie or by suture ligation. This procedure is repeated until placement of the final clamp across the portion of the tube closest to the cornua.
In approximately 5 to 30 percent of patients, complete salpingectomy at the time of cesarean birth cannot be performed, and the procedure must be converted to a partial salpingectomy [14,15]; adhesive disease is a commonly cited reason. Similar data are not available for complete salpingectomy performed after vaginal birth; the procedure is more difficult at this time because a small infraumbilical incision is used and there is limited access and visibility of the fallopian tubes.
Titanium clip — Use of the titanium clip (Filshie clip (picture 1 and figure 8)) has been proposed for postpartum permanent contraception based upon ease of use and shorter operative duration ; however, the failure rate with the clip appears to be unacceptably high in this population, and we, therefore, recommend against the use of the titanium clip for postpartum permanent contraception.
In a randomized trial (n = 1400) comparing the titanium clip with the Pomeroy method in the postpartum period, the failure rate at 24 months was fourfold higher for the clip (1.7 versus 0.4 percent) . A major limitation of this trial was a high rate of loss to follow-up of just over 50 percent in both groups. In addition, a systematic review that included the data from this trial as well as eight other comparative and noncomparative observational studies found that failure rates for postpartum permanent contraception with the titanium clip ranged from no failures to 8.4 percent .
The titanium clip is commonly used for interval laparoscopic permanent contraception in which it is more effective. This use is discussed in detail separately. (See "Female interval permanent contraception: Procedures", section on 'Titanium clip or spring clip'.)
POSTOPERATIVE CARE AND FOLLOW-UP — Short-term postoperative pain is expected following a tubal ligation due to the abdominal incision and potentially from ischemic tubal tissue. Rarely, patients are prescribed a limited number of oral narcotics to use for postoperative pain that is not controlled by nonsteroidal anti-inflammatory drugs or acetaminophen. Further discussion on pain management in the postpartum setting is discussed elsewhere. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Pain management'.)
There is no specific postoperative visit scheduled after postpartum permanent contraception procedures. Concerns regarding wound healing can be addressed as part of routine postpartum care.
Following complete or partial salpingectomy, final pathology reports should be reviewed to confirm that a complete tubal cross-section is documented for both specimens. If this is not confirmed, the patient will need to be advised that the permanent contraception was not successful and that an alternative contraceptive method is needed.
COMPLICATIONS — Overall, the rates of complications following mini-laparotomy for postpartum permanent contraception procedures are very low. In a study of 5095 patients in Switzerland, the rate of major morbidity after postpartum permanent contraception via mini-laparotomy was 0.39 percent (with the majority being estimated blood loss over 500 mL), and the rate of minor morbidity was 0.80 percent (with the majority being urinary tract infections and wound dehiscences) .
Efficacy — Postpartum permanent contraception is highly effective: poststerilization pregnancy occurs in <1 percent of partial salpingectomy procedures (table 2). The efficacy of postpartum permanent contraception was best demonstrated in the United States Collaborative Review of Sterilization (CREST), a multicenter study of 10,685 female patients who underwent permanent contraception procedures between the years of 1978 and 1987 . The median age of study subjects was 30 years. The 10-year failure rate for postpartum partial salpingectomy was 7.5 per 1000 procedures. The CREST study did not compare efficacy of different methods of partial salpingectomy, and there are no long-term data regarding efficacy of complete salpingectomy for permanent contraception.
Causes of failed permanent contraception procedures — Causes of failed permanent contraception include wrong structure occluded or resected (eg, round ligament), incomplete tubal occlusion, tuboperitoneal fistula formation, and spontaneous recanalization of the tubal lumen. (See "Female interval permanent contraception: Procedures", section on 'Causes of failed permanent contraception'.)
In these women, another form of birth control is necessary, and an interval permanent contraception procedure can be performed.
Other outcomes — Potential noncontraceptive effects (eg, changes in menstrual function, breast health) have been evaluated after permanent contraception. Tubal occlusion has been found to have little or no effect on menstrual function, ovarian reserve, or breast cancer risk. A full discussion about the potential noncontraceptive effects of permanent contraception can be found elsewhere. (See "Overview of female permanent contraception", section on 'Potential noncontraceptive effects'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Contraception" and "Society guideline links: Postpartum care".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Permanent birth control for women (The Basics)")
●Beyond the Basics topic (see "Patient education: Permanent birth control for women (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Postpartum permanent contraception procedures are performed immediately after childbirth. Postpartum permanent contraception procedures are typically performed within 24 to 48 hours following a vaginal birth or at the time of cesarean birth. (See 'Introduction' above.)
●The surgical approach for postpartum permanent contraception depends upon the route of delivery. The fallopian tubes are resected after closure of the hysterotomy if a cesarean birth was required. Postpartum permanent contraception after a vaginal birth is performed via an infraumbilical mini-laparotomy. (See 'Surgical approach' above.)
●There are a variety of options for the method of tubal occlusion used for postpartum permanent contraception (see 'Our approach' above):
•For most patients, we suggest partial salpingectomy rather than complete salpingectomy for postpartum permanent contraception (Grade 2C). Partial salpingectomy is effective, time-efficient, and with less potential for serious bleeding than complete salpingectomy. (See 'Partial salpingectomy' above and 'Complete salpingectomy' above.)
•The specific method of partial salpingectomy is based on the surgeon's experience and preference. In our practice, we find the Parkland or Pomeroy methods to be the most time-efficient. (See 'Partial salpingectomy' above.)
•Complete salpingectomy has the potential beneficial effect of decreasing ovarian cancer risk and may be a good choice for some postpartum patients. (See 'Complete salpingectomy' above.)
●For all methods, it is essential to correctly identify the fallopian tubes to ensure that the correct structure is occluded and thereby avoid a failed permanent contraception procedure. Following partial salpingectomy, final pathology reports should be reviewed to confirm that the tubal cross-section is documented for both specimens. If not confirmed, the patient will need to be advised that the permanent contraception procedure was not successful and that an alternative contraceptive method is needed. (See 'Procedure' above and 'Postoperative care and follow-up' above.)
●The risk of complications following postpartum salpingectomy by mini-laparotomy is overall very low. Care should be taken to prevent trauma to the secured tubal stumps when returning the tube to the abdomen in order to avoid excess blood loss. (See 'Complications' above.)
●In the United States Collaborative Review of Sterilization (CREST) study, the 10-year failure rate for postpartum partial salpingectomy was 7.5 per 1000 procedures. This was lower than other methods, although all methods had a failure rate of <1 percent (table 2). (See 'Efficacy' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Thomas Stovall, MD, and William Mann, Jr, MD, who contributed to an earlier version of this topic review.