Female interval permanent contraception: Procedures

INTRODUCTION — Several techniques are available that provide permanent contraception (also referred to as sterilization or tubal ligation) for female patients. The most common techniques prevent pregnancy by removing or disrupting the patency of the fallopian tubes.

Female permanent contraception may be performed immediately after childbirth (postpartum) or at a time unrelated to a pregnancy (interval). Most postpartum permanent contraception procedures are performed at the time of cesarean birth or after a vaginal birth via mini-laparotomy. Most interval permanent contraception procedures are performed via laparoscopy.

This topic review will focus on female interval (laparoscopic) permanent contraception. An overview of general principles of female permanent contraception as well as postpartum and hysteroscopic permanent contraception procedures are discussed separately.

●(See "Overview of female permanent contraception".)

●(See "Postpartum permanent contraception: Procedures".)

Interval permanent contraception could previously be performed via hysteroscopy; however, there are now no methods of hysteroscopic permanent contraception available. (See "Hysteroscopic female permanent contraception".)

In this topic, we will use the terms "patients" or "females" when discussing the counseling and treatment for permanent contraception procedures. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals. Terminology that some individuals may find more fitting includes "pregnancy-capable individuals" or "assigned female at birth."

INDICATIONS AND CONTRAINDICATIONS — The only indication for a permanent contraception procedure is the patient's desire for permanent contraception. Ultimately, the choice is made by the patient, but the decision requires thorough counseling about permanence and the risk of regret.

There are no medical conditions that are strictly incompatible with laparoscopic procedures; however, there may be factors that make individuals more suitable for a particular route of permanent contraception procedure or other contraceptive options. (See "Overview of female permanent contraception", section on 'Assessing surgical risk'.)

PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation and preparation items for laparoscopic permanent contraception are listed briefly here and discussed in more detail separately (see "Overview of female permanent contraception", section on 'Preoperative evaluation'):

●Counseling about alternatives to permanent contraception, types of permanent contraception procedures, efficacy and permanence, and risk factors for regret. Informed consent is obtained about the chosen permanent contraception technique. (See "Overview of female permanent contraception", section on 'Counseling'.)

●Assessment of surgical risk for a laparoscopic procedure and appropriate consultation and preoperative testing if medical comorbidities are present. (See "Overview of preoperative evaluation and preparation for gynecologic surgery".)

●Pregnancy testing. (See "Overview of female permanent contraception", section on 'Pregnancy testing'.)

●Antibiotic prophylaxis is not typically required for laparoscopic permanent contraception procedures (table 1). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Gynecologic and obstetric surgery'.)

●Thromboprophylaxis is not typically required for patients at low risk of venous thromboembolism for laparoscopic permanent contraception procedures. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients", section on 'Assess risk for thrombosis'.)

PROCEDURE — Methods of tubal excision or occlusion for female permanent contraception include complete salpingectomy, electrosurgical desiccation mechanical methods (silicone band, titanium clip, or spring clip), and partial salpingectomy.

Identification of the tubes — An essential step, regardless of approach, is the correct identification of the fallopian tubes, which may be more difficult in the setting of prior pelvic surgery, endometriosis, or uterine anomalies. Once identified, the tubes should be confirmed as the correct structures by examining them bilaterally along their full length to visualize the fimbriated end. This also helps to prevent failure of the intended permanent contraception procedure and avoid surgical interruption of other structures (eg, round ligaments).

Laparoscopy — The incision and closure for a laparoscopic female permanent contraception procedure are the same as for other laparoscopic gynecologic procedures. General principles of laparoscopy are discussed in detail separately. (See "Anesthesia for laparoscopic and abdominal robotic surgery in adults" and "Nerve injury associated with pelvic surgery" and "Abdominal access techniques used in laparoscopic surgery" and "Instruments and devices used in laparoscopic surgery".)

A common approach is to use two to three laparoscopic ports: at a minimum, use of an umbilical port for the laparoscope and a midline suprapubic port or bilateral lower quadrants ports for the other instruments are required to safely and effectively complete the procedure.

Some surgeons prefer to do the procedure through a single incision. Traditionally, this was done through an operative laparoscope that had a channel for the camera and another for instruments. However, this technique is limited by inability to apply traction and optimal positioning of an occlusive device. Development of single-incision laparoscopic surgery (SILS) has allowed performance of many surgical procedures through a single port (see "Abdominal access techniques used in laparoscopic surgery", section on 'Single-incision laparoscopic surgery'). For laparoscopic permanent contraception, however, single-incision techniques likely offer minimal advantages. Multiple-incision laparoscopic permanent contraception can be accomplished with three, less commonly two, small (5 mm) incisions and with instrumentation that is readily available in most operating room settings in the United States. Placement of a uterine manipulator can improve the ability to achieve optimal positioning and grasping of the fallopian tube. We routinely use a 5 mm port at the umbilicus for placing the laparoscope; a potential disadvantage of use of the operative laparoscope or the SILS technique is that both require a larger umbilical incision.

There are no comparative data regarding the efficacy or complications rates associated with tubal ligations performed with multiple or single laparoscopic ports.

Complete salpingectomy — In our practice, we routinely discuss the option of complete salpingectomy with the patient and review the potential benefits and risks as part of the informed consent process. We review the theoretical reduction in risk of ovarian cancer, potential for decreased future morbidity, and minimal or negligible increased risk of surgical complications.

Utilization — Complete salpingectomy has not traditionally been the method of choice for laparoscopic permanent contraception since electrosurgical and mechanical techniques have been thought to be technically easier and associated with a lower risk of complications (eg, bleeding); however, rates of complete salpingectomy for permanent contraception are increasing. A retrospective review of a single large health care system showed that from 2011 to 2016 the proportion of complete salpingectomy done for interval permanent contraception increased from 1 to 78 percent [1]. In this study, median operative minutes for interval permanent contraception increased from 30 to 33, and there was no difference in operative blood loss. Another large observational study of 14,886 patients in British Columbia compared completed salpingectomy for permanent contraception with other methods of interval permanent contraception and found no increase in complication rates and an increase in operative time of approximately 10 minutes [2]. Similarly, a case series of 81 salpingectomies and 68 tubal occlusions performed using the ring (19.1 percent), bipolar electrosurgery (32.4 percent), or titanium clip (47.1 percent) showed comparable immediate and short-term complication rates across permanent contraception methods and an average increase of six minutes of operative time for salpingectomy [3]. One caveat regarding salpingectomy is that it may not be technically feasible or may have an increased risk of complications in patients with significant pelvic adhesions, endometriosis, or abnormal anatomy. In terms of efficacy, removal of the entire fallopian tube bilaterally theoretically increases the effectiveness and reduces the risk of needing subsequent surgery for ectopic pregnancy or hydrosalpinx [4].

The increased interest and rising frequency of complete salpingectomy is based on a potential reduction in ovarian cancer risk. The rationale for this approach and the technique for laparoscopic salpingectomy are discussed in detail separately. (See "Opportunistic salpingectomy for ovarian, fallopian tube, and peritoneal carcinoma risk reduction".)

Complete salpingectomy technique — After the laparoscopic ports have been placed, identify both fallopian tubes. If significant adhesions are present these can be released or dissected free with caution. In some cases, adhesions involving the fimbria or distal end of the tube to structures (eg, bowel, peritoneum overlying major pelvic vessels) may warrant a decision to perform a different permanent contraception technique to minimize the potential complications associated with the extensive dissection needed to perform complete salpingectomy.

Next, identify the adjacent structures, including the ureter and the ovarian vascular supply (infundibulopelvic ligament). Using an electrosurgical device, the tube is excised starting at either the lateral or medial aspect, with care taken to avoid thermal injury to the ovarian vasculature. The medial stump of the tube should be thoroughly desiccated to minimize development of a tuboperitoneal fistula as "stump" pregnancies have been described [5]. There is no evidence to recommend an optimal location on the cornua or medial aspect of the fallopian tube for excision, but we prefer to leave a stump of at least 1 cm to allow for good control of hemostasis and additional desiccation at this site. The fallopian tubes are then either removed directly through the ports or placed in a laparoscopic retrieval bag for removal.

A transvaginal natural orifice approach for salpingectomy has also been described as a comparable and less painful technique and may be useful in patients with a higher body mass index (BMI) [6].

Tubal occlusion techniques — When a tubal occlusion technique is chosen, tubal occlusion or desiccation should be performed on the mid-isthmic portion of the tube (figure 1), regardless of the specific permanent contraception technique. The proximal isthmus (immediately adjacent to the cornua) should be avoided to reduce the theoretical risk of fistula formation between the interstitial portion of the tube and the peritoneal cavity [7]. Surgery for permanent contraception performed on the distal portion of the tube may increase risk of injuring adjacent structures, and distal fimbriectomy has been associated with higher risk of failure [8].

The most common methods of tubal occlusion in current practice are electrosurgical desiccation with bipolar grasping forceps, a silicone band, or a titanium clip. Based upon data from the original Collaborative Review of Sterilization (CREST) study, subsequent follow-up estimates of the bipolar method, as well as studies of the titanium clip, all methods are comparably safe and effective, with complication and failure rates of <1 percent (table 2) [9,10] (see 'Complications' below and 'Efficacy' below). Thus, choice of technique for occlusion should be guided by the experience of the surgeon, available equipment, technical ease, and cost.

In our practice, we use bipolar desiccation with a blended cutting and coagulation energy pattern (the red "Wolf" generator creates a blend of cutting and coagulation) with Kleppinger forceps. This method is technically easy and is locally available to us. Compared with mechanical methods for tubal occlusion, electrosurgery employs reusable, and therefore lower cost, instrumentation. Bipolar electrosurgery is associated with less postprocedural pain compared with silicone bands but may have greater risk of ectopic pregnancy. If a mechanical method is chosen, the titanium clip appears to be associated with lower risk of mesosalpingeal injury than silicone bands. (See 'Complications' below.)

As a reason for selection of a tubal occlusion technique, we do not consider the potential for improved reversibility with techniques that minimize tubal damage (eg, from clips or band). Tubal interruption is intended to be permanent, and patients should be told this without exception as part of the consent process. Individuals interested in potential reversibility should be counseled to avoid permanent contraception procedures and instead consider long-acting reversible contraceptives (intrauterine devices or the implant), given the comparable efficacy of these options compared with permanent contraception. (See "Overview of female permanent contraception", section on 'Counseling and informed consent'.)

Electrosurgery — Radiofrequency energy is employed to desiccate the fallopian tubes and the adjacent mesosalpinx, resulting in occlusion by destruction/obliteration of the tubal lumen.

Use of the Kleppinger bipolar electrosurgical grasping forceps for tubal fulguration has been studied to evaluate the ideal settings and application to achieve effective occlusion [11]. Other electrosurgical methods, such as an ultrasonic or vessel-sealing device, have not been evaluated specifically for tubal occlusion and are not approved for this indication.

To perform the procedure, the surgeon grasps the full thickness of the tube between the two prongs of a bipolar device such as the Kleppinger forceps and then activates the electrical generator (figure 2). This is then repeated for contiguous segments of tube at a minimum of three sites.

The steps used to ensure that the tube is adequately occluded when using bipolar electrosurgery with the Kleppinger forceps are the following:

●A segment of at least 3 cm of the tube should be fulgurated. This recommendation is based on a reanalysis of failures following bipolar electrosurgery for permanent contraception in the CREST cohort. When electrosurgery was applied to three contiguous sites on the fallopian tube (a total length of fulguration of approximately 3 cm) the failure rate of the bipolar electrosurgery technique approached the lowest reported range for laparoscopic permanent contraception (3.2 per 1000 procedures); in comparison, if fewer than three sites of electrosurgery were applied, the probability of failure was 12.9 per 1000 procedures [12].

A visual appearance of "blanching" (tube turning white) of tubal tissue is not sufficient to conclude the tube is adequately occluded. As an example, in one study of bipolar electrosurgical permanent contraception procedures in patients immediately prior to hysterectomy, histologic evidence of desiccation was found consistently with use of an undamped waveform (traditionally referred to as a cutting waveform) and a power of at least 25 watts. With a damped (coagulation) waveform, complete desiccation was found only with much higher settings [13]. The current electrosurgical unit offered by the manufacturer of the Kleppinger forceps produces a primarily undamped waveform [14].

The surgeon and operating room staff must make sure that the correct electrosurgical generator is connected to the Kleppinger bipolar grasping forceps to minimize risk of ineffective tubal desiccation. In addition, an optical and/or audible inline current meter should be used by the operator to determine the end point. The meter allows application of radiofrequency energy until there is no further resistance from viable tissue [13].

Historically, monopolar electrosurgery was used when laparoscopic permanent contraception was first introduced. We recommend not using monopolar electrosurgery for tubal permanent contraception due to the risk of thermal injury. Inadvertent thermal burn to structures including the bowel has been described in case reports and small case series with monopolar devices for permanent contraception; several cases of death due to resulting sepsis have been reported [7,15-17].

Silicone band — Placement of a silicone band (Falope-Ring) around a folded loop of fallopian tube was developed by Yoon and colleagues in the early 1970s as a safer and effective alternative to monopolar electrosurgery [18].

The band is made of a nonreactive silicone rubber that incorporates a solution of 5 percent barium sulfate to permit radiologic identification. The band is 2.2 mm thick with an outer diameter of 3.6 mm and an inner diameter of 1 mm. It possesses a specific elastic power with a recovery of 90 to 100 percent, if not stretched to more than 7 mm.

The band is placed using a special applicator. The silicone band is stretched over the end of the applicator immediately prior to device insertion through the laparoscopic port. The applicator has prongs within the sheath, which are carefully advanced, and used to gently grasp the isthmic portion of the fallopian tube (figure 3). The prongs are retracted, elevating the tube into the sheath of the applicator. The band is then deployed, placing it at the base of a loop of tube that is 1.5 to 2 cm in length (figure 4 and figure 5). The tube must be grasped and elevated carefully to avoid laceration to the tube and/or mesosalpinx. With time, the loop of tube will necrose and result in interruption of tubal patency.

Titanium clip or spring clip — Two clips are available for tubal occlusion in the United States: the titanium clip (Filshie clip) and the spring clip (Hulka clip).

The titanium clip appears to be more effective than the spring clip. A randomized trial that included 599 patients who underwent laparoscopic permanent contraception with a clip and had long-term follow-up found that the failure rate was significantly lower at 24 months with the titanium compared with the spring clip (9.7 versus 28.1 pregnancies per 1000 women) [19]. Also, in the CREST study, the spring clip was the least effective method, but this study did not include the titanium clip [10]. (See 'Efficacy' below.)

Both types of clips are placed using specially-designed reusable applicators. The clip is attached to the applicator outside the patient. The clip is partially closed as it is advanced through the laparoscopic port, and then advanced toward the fallopian tube in an open position to facilitate light grasping and positioning. The clip is applied perpendicular to the isthmic portion of the tube and advanced until the distal end is across the tubal lumen; it is then closed. Correct placement is essential to ensure complete occlusion. Clips are left permanently in place and become peritonealized as the tube necroses and heals.

Individual characteristics of each clip include:

●The titanium clip is composed of a titanium outer sheath lined by a silicone pad (picture 1). The reusable titanium clip applicator requires a 7 mm trocar for placement, with a 5 mm option available for single-incision laparoscopic surgery. Once the lower jaw of the clip is visible through the mesosalpinx just below the tube, the applicator handle is slowly but firmly squeezed to secure the clip in place (figure 6). Once closed, a clip cannot be opened. If a clip is placed incorrectly, a second clip may be placed on the same tube, as close as possible to the first clip to minimize risk of hydrosalpinx formation [20].

There is no magnetic component of the titanium clip; therefore, it should be compatible with subsequent magnetic resonance imaging (MRI).

●The spring clip has toothed jaws of polycarbonate (Lexan) with a stainless steel fulcrum and a gold-plated spring-loaded mechanism to lock the clip in place (picture 2). The spring clip applicator requires access through a 7 mm port and allows the operator to open and close the clip to confirm correct placement before locking (figure 7). Once applied, the spring clip is designed to gradually apply pressure over 24 to 48 hours to occlude a 3 to 5 mm segment of the fallopian tube [7,21]. Application of spring clips may be difficult if the tubes are edematous. The manufacturer confirms that there is also no known adverse effect of MRI exposure for patients with the Hulka clip [22].

For the methods described above using a band or clip to occlude the tube, abnormal tubal anatomy (for example, dilated tubes from prior infection) will interfere with correct and effective placement of the occlusive device. These methods should not be used for patients with known tubal disease.

Mini-laparotomy — In many countries, laparoscopic equipment is not readily available, and mini-laparotomy for interval permanent contraception is performed [23]. Often, this is performed using local anesthesia. The procedure is similar to that performed after a vaginal birth; however, due to an involuted uterus, the location of the incision is in the suprapubic area, rather than infraumbilical, and may require a slightly larger incision of 3 to 5 cm. A uterine manipulator or uterine elevator can be used to lift the uterine fundus into view and a Babcock clamp can be used to grasp and elevate the fallopian tubes. The tubal ligation can then be performed using one of the methods for partial or complete salpingectomy. (See "Postpartum permanent contraception: Procedures", section on 'Procedure'.)

FOLLOW-UP — Postoperatively, patients are instructed to avoid intercourse for three weeks, though this is based on consensus rather than evidence.

The laparoscopic permanent contraception procedure is immediately effective, so other methods of contraception can be discontinued.

Most patients should be able to return to work after one week unless they have particularly strenuous job requirements. We see patients for a postoperative clinic visit within two to four weeks after their operation.

COMPLICATIONS — Complications specifically associated with laparoscopic permanent contraception procedures are discussed here; general complications of laparoscopic surgery are discussed in detail separately. (See "Complications of laparoscopic surgery".)

Analysis of interval laparoscopic procedures in the United States Collaborative Review of Sterilization (CREST) cohort concluded that the overall rate of intraoperative and postoperative complications was 1.6 per 100 women [24]. When major surgeries that were not related to laparoscopic permanent contraception procedures were excluded, the rate was reduced to 0.9 per 100 women. There were no deaths and only one report of a life-threatening event among 9475 procedures.

Complications rates among the four most commonly referenced methods of laparoscopic tubal permanent contraception (silicone band, spring clip, bipolar or monopolar electrosurgery) ranged from 1.17 to 1.95 per 100 procedures in the CREST population. There was no statistically significant difference in complication rates between these techniques. Patient history of diabetes, general anesthesia, and previous abdominal or pelvic surgery were all found to be predictors of increased morbidity related to interval tubal permanent contraception [25]. There have not been any studies since CREST with a denominator large enough to rigorously compare complication rates between the more common modern methods of laparoscopic permanent contraception. A meta-analysis of 19 randomized trials demonstrated that the silicone band compared with the titanium clip had a higher rate of minor procedure-related injuries with no additional operation (4.6 versus 2.4 percent, odds ratio [OR] 1.95, 95% CI 1.36-2.78) and technical failures (3.3 versus 0.7 percent, OR 3.93, 95% CI 2.43-6.35) [26].

Another observational study, of 44,278 procedures in New York State between 2005 and 2013, reported the rate of iatrogenic complications (hemorrhage or hematoma complicating a procedure, and accidental puncture or laceration) to be 0.4 percent within 30 days following laparoscopic permanent contraception procedures. The rate of major medical complications (acute myocardial infarction, stroke, pulmonary embolism, perioperative shock, and respiratory complications) was reported to be 0.1 percent [25]. Both studies confirm that, overall, laparoscopic permanent contraception procedures are very safe.

Most studies evaluating complication rates between complete salpingectomy, partial salpingectomy, or tubal occlusion have been in the postpartum period (see "Postpartum permanent contraception: Procedures", section on 'Complete salpingectomy'). A few small retrospective studies have compared complications between laparoscopic tubal occlusion and complete salpingectomy [27,28]. While complication rates trended lower in the complete salpingectomy group, this was not statistically significant, though these studies were likely underpowered to detect such a difference.

Immediate complications — Immediate complications from surgical permanent contraception procedures may include bleeding, injury to other structures, or pain.

Bleeding — Bleeding may occur from the tube or mesosalpinx due to excessive traction during surgery or from trauma during placement of occlusive devices. In such cases, bleeding may be controlled with bipolar electrosurgery or with application of additional silicone bands or clips. Tubal transection may occur if a clip is placed too quickly; slow gradual pressure is advised to "milk away" any tubal edema present [9].

Some surgeons report that in their practice there is less risk of transecting the tube and related bleeding complications during application of the clip compared with the silicone band [9]. A randomized trial using the titanium clip compared with the silicone band reported tubal or mesosalpingeal injury in 2 out of 904 (0.2 percent) of laparoscopic clip procedures, compared with 23 out of 880 (2.5 percent) of the silicone band procedures [29].

Injury to nearby structures — If salpingectomy is performed for permanent contraception, care should be taken to avoid excessive electrosurgery adjacent to the infundibulopelvic ligament. Identification of the infundibulopelvic ligament is crucial to avoid compromising ovarian blood flow, and if the vessels are divided inadvertently, significant bleeding can result. Venous structures in the mesosalpinx are another potential source of bleeding if the tube is grasped with excessive force or manipulated with a laparoscopic grasper that has teeth or sharp components, including the silicone band applicator.

Conversion to laparotomy — In the CREST study, conversion from laparoscopy to laparotomy to complete the permanent contraception procedure due to complications specific to laparoscopic technique (such as injury to other structures at time of entry) occurred in only 14 out of 9475 procedures (0.15 percent). Nine laparotomies were performed for findings of incidental disease, 37 due to difficult visualization or mobilization of the fallopian tubes, four for equipment malfunction, three for unknown reasons, and 21 for patients in whom entry or pneumoperitoneum could not be obtained, for a total laparotomy rate of 0.09 percent [24]. The risk of conversion to laparotomy in current practice is likely to be even lower, given improvements in laparoscopic skill and technique since the CREST study was conducted.

Postoperative pain — Short-term postoperative pain is expected following laparoscopic gynecologic surgery due to the abdominal incisions and to diaphragmatic irritation from residual intraperitoneal carbon dioxide, as occurs after other laparoscopic surgeries. Most surgeons prescribe a limited number of oral narcotics to use for postoperative pain not controlled by the use of nonsteroidal anti-inflammatory drugs or acetaminophen during the first one to five days. For most patients, any severe pain is resolved by the third postoperative day [30].

The silicone band and clips appear to cause more postoperative pain than electrosurgery. This is likely because both these methods result in ischemic tubal tissue. Two studies included in a meta-analysis of randomized trials of methods for tubal occlusion compared postoperative pain (<24 hours) among patients undergoing laparoscopic permanent contraception via silicone band or electrosurgery. The combined analysis showed significantly more pain with silicone bands as compared with electrosurgery (OR 3.40, 95% CI 1.17-9.84) as well as higher postoperative analgesia use (OR 2.51, 95% CI 1.00-6.30). There was no difference in persistent pain at the follow-up visit [31]. Data are conflicting regarding whether the clip or silicone band is more painful [32,33].

In randomized trials, use of a bupivacaine at time of laparoscopic permanent contraception with silicone bands or titanium clips has been found to decrease postoperative pain scores compared with placebo [34,35]. Using a cannula placed through a lower port site, the surgeon can drip 5 mL of 0.5 percent bupivacaine along the tube from the uterus to the fimbria bilaterally prior to tubal occlusion.

Delayed complications

Ectopic pregnancy — Ectopic pregnancy is the most serious delayed complication, since unrecognized tubal rupture remains a significant contributor to maternal mortality in early pregnancy. Overall, ectopic pregnancies accounted for 32.9 percent of all pregnancies reported in CREST subjects, for an ectopic pregnancy rate of 7.3 per 1000 permanent contraception procedures [36].

Patients under age 30 years at time of permanent contraception had higher rates of ectopic pregnancy compared with older patients, except for those under 30 years sterilized by postpartum partial salpingectomy. The risk of ectopic pregnancy did not significantly vary with length of time since the permanent contraception procedure.

In the original CREST study, bipolar electrosurgery resulted in the highest probability of ectopic pregnancy (17.1 per 1000 procedures at 10 years after permanent contraception), and postpartum partial salpingectomy resulted in the lowest (1.5 per 1000 procedures at 10 years after permanent contraception) [36]. The rate of ectopic pregnancy is likely much lower using modern techniques, since reanalysis of the CREST data suggests that applying bipolar electrosurgery to three adjacent sites on the tube dramatically decreases the cumulative pregnancy rate to 3.2 per 1000 procedures [12]. (See 'Efficacy' below.)

Incorporating more modern methods, an analysis of 44,829 patients undergoing tubal permanent contraception procedures in Western Australia from 1990 to 2010 identified 89 patients with subsequent ectopic pregnancy for a cumulative probability of 1.7 per 1000 procedures at five years, 2.4 per 1000 by 10 years, and 3 per 1000 by 15 years after surgery [37]. Differences in probability varied by age (highest for younger patients) and by method, though they disclose that 40 of the 89 patients with ectopic pregnancy had a laparoscopic permanent contraception procedure by an unspecified method of destruction or occlusion. Bipolar electrosurgery by laparoscopy had a reported risk of ectopic pregnancy of 8.4 per 1000 procedures at 5 and 10 years after surgery. Following laparoscopic occlusion with the titanium clip, the probability of ectopic pregnancy was only 1.7 per 1000 procedures at five years and 2.0 per 1000 at 10 years after permanent contraception. Laparoscopic or open salpingectomy and hysteroscopic permanent contraception procedures were not commonly performed, but not associated with subsequent ectopic pregnancy in this analysis.

Ectopic pregnancy is covered in detail separately. (See "Ectopic pregnancy: Clinical manifestations and diagnosis" and "Ectopic pregnancy: Methotrexate therapy".)

Device migration — For permanent contraception procedures using a clip, delayed migration or expulsion via the urethra, bladder, vagina, or rectum have been reported, but are uncommon events. Based upon available data, it appears that such events are not associated with failed tubal occlusion or other significant morbidity, as the tubal segment remains obstructed from the previous clip placement [9,38]. Silicone bands are often seen to be peritonealized and still attached to the mesosalpinx or even found elsewhere in the pelvis at the time of subsequent surgery, with no reports of failure or adverse outcomes related to migration.

OUTCOME — Female surgical permanent contraception is highly effective, and post-procedure pregnancy occurs in <1 percent of patients (table 2) [10].

Efficacy

CREST data — The best available data regarding the efficacy of female permanent contraception procedures in the United States are from the Collaborative Review of Sterilization (CREST), a multi-center study of 10,685 patients who had a permanent contraception procedure between the years of 1978 and 1987 [10]. The median age of study subjects was 30 years. The methods available at the time of the study were mini-laparotomy (both postpartum and interval) and laparoscopic permanent contraception using silicone bands, spring clips, or bipolar or monopolar electrosurgery. Since the CREST study data were collected, monopolar electrosurgery has been replaced by bipolar electrosurgery and titanium clips have been introduced. (See 'Electrosurgery' above and 'Titanium clip or spring clip' above and "Hysteroscopic female permanent contraception".)

Overall, for all methods of permanent contraception CREST found a 10-year cumulative failure rate of 18.5 per 1000 women (143 total failures).

Ten-year failure rates in CREST varied by the method of permanent contraception employed (table 2) [10]:

●Monopolar electrosurgery (7.5 per 1000 procedures)

●Postpartum partial salpingectomy (7.5 per 1000)

●Silicone band (17.7 per 1000)

●Interval partial salpingectomy (20.1 per 1000)

●Bipolar electrosurgery (24.8 per 1000) (revised to lower estimate of 3.2 to 6.3 per 1000 in follow-up analysis, refer below)

●Spring clip application (36.5 per 1000)

The differences in efficacy between methods of permanent contraception diminished with increasing age at time of surgery, with no statistical differences in 10-year efficacy rates between methods among patients 34 years or older at the time of the procedure [10]. The most likely explanation for this is that with decreased fertility and fewer potential years of fertility at older ages, the small differences in efficacy between methods become insignificant.

In a multivariable analysis that included age at permanent contraception, race/ethnicity, and study site, the method of permanent contraception remained a statistically significant risk factor for failure [10]. Interval partial salpingectomy, spring clip application, and bipolar electrosurgery were more likely to result in failure than postpartum partial salpingectomy, silicone rubber band application, and monopolar electrosurgery. In terms of age, using patients ages 28 to 33 years as the standard, the risk was higher for patients who underwent permanent contraception at ages 18 to 27 years (1.25-fold) and lower in those ages 34 to 44 years (0.46-fold). Race/ethnicity was also found to be a significant risk factor for contraception failure in the multivariate analysis, with Black non-Hispanic patients having a 2.5-fold greater risk of failure than White, non-Hispanic patients.

Since the initial CREST study was published in 1996, additional data regarding the efficacy of various methods have emerged. Follow-up analysis of CREST data looked specifically at the use of bipolar electrosurgery over the study period and found that the five-year cumulative failure rates decreased dramatically over this period with changes in technique [12]. They found that five-year failure rates were 19.5 per 1000 for women sterilized between the years of 1978 and 1982, but that the failure rate had dropped to 6.3 per 1000 among those sterilized between the years of 1985 and 1987. Additionally, patients sterilized in these last two years of the study who had three or more sites of desiccation along the fallopian tube had a five-year failure rate of 3.2 per 1000, equivalent or better efficacy than monopolar electrosurgery and silicone band application.

Titanium clip — Titanium clips (Filshie clips) were not in use in the United States at the time of the CREST study. Failure rates for the titanium clip for interval laparoscopic permanent contraception have been reported between 0 and 0.4 percent based on four studies with 6 to 15 years of follow-up, which is comparable if not slightly better than methods from the CREST study [9].

Other efficacy data — A meta-analysis of 19 randomized trials found the following [26]:

●The silicone band compared with clip (trials evaluated all types of clips, including spring, titanium, and other clips; four trials) had comparable efficacy with failure rates <1 percent (0.6 versus 0.8 percent, odds ratio [OR] 0.72, 95% CI 0.33-1.57).

●Silicone band compared with electrocoagulation did not have sufficient data for meta-analysis, since there were two trials and one had no failures (n = 298) [39] and the other trial (n = 298) had no failures in the band group and no failures in the electrocoagulation group.

●Spring clip (Hulka) and titanium clip (Filshie) efficacy were compared in only one trial (n = 1441), which found a trend toward a lower failure rate with the spring clip, but this did not reach statistical significance (0.8 versus 0.1 percent, OR 6.2, 95% CI 0.75-51.66) [19].

●Modified Pomeroy partial salpingectomy via mini-laparotomy versus electrocoagulation via laparoscopy for interval permanent contraception was evaluated in one trial (n = 295) with one pregnancy reported in the Pomeroy group, resulting in no statistical difference (OR 4.47, 95% CI 0.07-286.78).

A large study that examined payment data from Quebec, Canada, during the years 1980 to 1999 found that, among 311,960 patients, 0.9 percent experienced a pregnancy after permanent contraception within 10 years of the procedure, a rate that was approximately half that in CREST. Similar to CREST, younger age was associated with higher failure rates. The Canadian study included both interval and postpartum permanent contraceptive procedures, but was not able to analyze failures according to surgical method. The authors hypothesized that their lower rate of permanent contraception failure might be due to (1) minimal use of the Hulka clip in Canada, which had the highest failure rate (10-year failure rate of 36.5 per 1000) and was performed in 15 percent of procedures in CREST and (2) procedures were performed in all hospital settings in Quebec, not just in teaching hospitals as was the case in CREST [40]. Together with the reanalysis of the efficacy of bipolar electrosurgery and the efficacy data on the titanium clip, this study further supports that with most modern methods, the failure rate of laparoscopic tubal ligation is less than 1 percent.

While complete salpingectomy theoretically should have an efficacy rate that approaches 100 percent and eliminates the risk of tubal ectopic pregnancy, no efficacy data currently exist.

Causes of failed permanent contraception — Presumed mechanisms for failure resulting in unintended pregnancy following surgical occlusion or resection of the fallopian tubes, and suggestions to avoid these errors, include:

●Luteal phase pregnancy – Timing of the permanent contraception procedure should be planned to exclude the risk of preexisting pregnancy. (See "Overview of female permanent contraception", section on 'Pregnancy testing'.)

●Wrong structure occluded or resected – Limited visualization through a mini-laparotomy incision, congenital uterine anomalies, or other pre-existing gynecologic pathology can compromise the surgeon's ability to identify or access the fallopian tube. Most experts advise to avoid this problem by routine identification of the fimbriated end of the fallopian tube and, for salpingectomy, histopathologic examination of the resected segments to avoid this problem [23].

●Incomplete tubal occlusion from a defective device, improper positioning, or incomplete desiccation [38]. At least two laparoscopic ports rather than a single port allow for improved visualization and traction on the fallopian tube prior to clip or band placement compared with single port technique [23]. As described above, improper use of bipolar electrosurgery may result in an intact endosalpinx [41]. (See 'Electrosurgery' above.)

●Tuboperitoneal fistula formation and spontaneous recanalization of the tubal lumen have been documented by pathologic examination following failure of permanent contraception; however, the pathogenesis for these events is unknown. Fistula formation has been documented in permanent contraception failures following monopolar electrosurgery [41]. One expert has suggested that a proximal tubal stump of at least 1 to 2 cm may prevent intrauterine fluid pressure from compromising healing and theoretically predisposing to fistula formation [23].

Other outcomes — The risk of permanent contraception regret is discussed in detail separately. (See "Overview of female permanent contraception", section on 'Regret after permanent contraception procedures'.)

Studies have evaluated the risks of reproductive (eg, effects on menstrual function) or breast health effects following permanent contraception. (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".)

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 5^th to 6^th 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 10^th to 12^th 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

●Methods – Female permanent contraception (also referred to as tubal ligation) can be performed by excision (complete or partial salpingectomy) or tubal occlusion (electrosurgical desiccation, silicone band, titanium clip, spring clip). Laparoscopic techniques are the most common approach to interval female permanent contraception (procedures that are not performed during the postpartum period). (See 'Introduction' above and 'Procedure' above.)

●Patient selection – The only indication for permanent contraception is the patient's desire for permanent contraception. There are no medical conditions that are strictly incompatible with laparoscopic permanent contraception procedures; however, there may be factors that make individuals more suitable for a particular type of procedure or other contraceptive options. (See 'Indications and contraindications' above.)

●Complete salpingectomy – In our practice, we routinely offer the option of complete salpingectomy and review potential benefits (reduction in ovarian cancer risk) and risks as part of the informed consent process. Salpingectomy has not traditionally been the method of choice for laparoscopic permanent contraception, since electrosurgical and mechanical techniques are thought to be technically easier. However, providers are more frequently offering patients the option based on the trend towards opportunistic salpingectomy, while becoming more facile with the technique. Data suggest that salpingectomy does not increase the risk of complications compared with other permanent contraception techniques. (See 'Complete salpingectomy' above.)

●Tubal occlusion techniques

•Effective permanent contraception methods involving occlusion are performed on the mid-isthmic portion of the tube (figure 1). The proximal isthmus (immediately adjacent to the cornua) should be avoided to reduce the theoretical risk of fistula formation between the interstitial portion of the tube and the peritoneal cavity. (See 'Tubal occlusion techniques' above.)

•Choice of technique for tubal occlusion should be guided by the experience of the surgeon and the equipment available. In our practice, we use bipolar electrosurgical desiccation with Kleppinger forceps. Compared with the band or clip, bipolar desiccation may be technically easier. Bipolar electrosurgical desiccation is associated with less postprocedural pain compared with silicone bands. However, there is concern that bipolar electrosurgery may increase the risk of ectopic pregnancy compared with other techniques, and for this reason, the titanium clip is preferred by some experts. The titanium clip appears to be associated with lower risk of mesosalpingeal injury than silicone bands. (See 'Tubal occlusion techniques' above.)

•For patients undergoing interval laparoscopic permanent contraception using the Kleppinger bipolar grasping forceps, we recommend that the tube be fulgurated along a 3 cm contiguous segment rather than separate areas of fulguration or a smaller segment (Grade 1B). A cutting waveform and a power of at least 25 watts is used to optimize desiccation and occlusion of the fallopian tube. For patients undergoing permanent contraception using electrosurgery, we recommend not using monopolar electrosurgery (Grade 1C). (See 'Electrosurgery' above.)

●Mini-laparotomy – In many countries, laparoscopic equipment is not readily available, and mini-laparotomy with either partial or complete salpingectomy is performed. (See 'Mini-laparotomy' above.)

●Complications – Observational studies report that interval laparoscopic permanent contraception is a very safe technique, with risk of major complications of <1 percent. The most concerning delayed complication is the risk of ectopic pregnancy, which is reported to occur in 3 to 7 per 1000 women. Complication rates are similar across the different tubal occlusion techniques. (See 'Complications' above.)

●Efficacy – Laparoscopic permanent contraception is immediately effective, so other methods of contraception can be discontinued. The risk of pregnancy following permanent contraception varies by the technique used for interval laparoscopic tubal occlusion, though studies confirm a failure rate of <1 percent across all currently used techniques. The differences in efficacy between methods of permanent contraception diminishes with increasing age, with no statistical differences in 10-year efficacy rates between methods among patients 34 years or older at the time of permanent contraception. (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.