Sterilization

December 14, 2007

Bilateral Tubal Ligation

Opening into the uterus (womb) are two openings that are the beginning of the fallopian tubes. The fallopian tubes continue away from the uterus and end around the ovaries so that these open ends will be close to where an egg is released with ovulation. Sperm from the vagina travel actively up the uterus, through the tubes to meet the egg that has been heading toward them from the other direction. A bilateral tubal ligation (BTL) is the surgical disruption of each of the two fallopian tubes that would otherwise allow up-current sperm to meet downstream egg. It can be done by securing a suture or clip around a portion on each side, burning a mid-segment of tube on each side, as in a laparoscopic procedure, or by tying knots and cutting between them on each side. The net result is a loss of continuity. If there's a roadblock to the sperm, the egg never gets fertilized, but is just resorbed each month.

Vasectomy

In a similar fashion, the two sperm ducts are separated so as to prevent sperm manufactured in the testicles to travel up to where they can be prepared for ejaculation. The scrotum, however, is not like entering the abdomen, as in a BTL, reducing the risk of serious infection and allowing for a local anesthetic.

Hysterectomy

Removing the uterus also, like a tubal ligation, leaves a sealed proximal end of each tube. But unlike a failed tubal causing pregnancy (failure rate 1:300-400), a hysterectomy pretty much makes pregnancy impossible. Of course, removal of the ovaries, with a hysterectomy, eliminates the source of egg release. Removal of the ovaries, oophorectomy, is surgical menopause as it pertains to fertility.

The Philosophical Aspects of Permanent Sterilization

Sterilize: To cause to become unfruitful; to deprive of the power of reproducing.

Even though it was God who said, Be fruitful and multiply,we've been trying to turn it off ever since. From the brutal and unthinkable practice of infanticide in less sophisticated times to the ideal of 2.3 children per family in modern times, there has always been a demand for methods to stop a couple from reproducing. What most people seldom think about, however, is the difference between contraception and sterilization.

Contraception is any method that reversably interferes with a couple's opportunity to conceive.

It doesn't eliminate the ability to conceive, however, which is what sterilization is designed to do. Contraception is temporary, sterilization should be considered permanent. Contraception involves the use of reversible techniques, like the birth control pill, the diaphragm, the IUD, condoms, spermicide, hormone shots and implants, and of course abstinence. Sterilization, on the other hand, puts up a permanent barrier to sperm meeting egg, such as tubal ligation, hysterectomy, and vasectomy. All of these methods have had a complicated history to get where they are today, and there have been many methods that have been discarded throughout history. All of these modern methods are accepted and legitimate, but most doctors have strong feelings about which ones they prefer and which ones they feel are unwise. Contraception itself is the subject of many different articles. I intend to concentrate, this time, on sterilization.

All Sterilizations Should Be Considered Permanent

Even the so-called reversible vasectomies and reversible tubal ligations should be considered permanent. This is because re-establishment of continuity for the traveling egg or sperm isn't always successful. Sometimes it can even be disastrous. For example, putting a woman's tubes back together may result in scar tissue, a bumpy ride for a fertilized egg that may result in an ectopic (tubal) pregnancy which usually means surgery, hemorrhage, or even death. Vasectomy reversals don't carry the same mortal fears, because all that might fail is sperm transport, not an actually fertilized egg on its way to implantation in the woman's uterus. But they are both surgeries fraught with limitations on their success, and you don't get your money back if there's a failure. And speaking of money, insurance isn't keen to cover a reversal; after all, why should they spend tens of thousands of dollars on something that if successful will result in a pregnancy that will cost them even more. So on top of the limited success surgically, anybody have a spare $20,000 liquid enough to slap down for a procedure that doesn't guarantee success?

The final word on this is look before you leap. Don't do any sterilization unless you're absolutely sure you will never want another child, no matter what--not in this life or any other.

The philosophical ramifications should also be mentioned. What if a woman's husband dies, and years later she meets a wonderful man who could provide for her children provided she can give him a child, too? To father a family can be a deal-breaker to someone who has no children of his own. What if there's a fire, God forbid, and all of her children perish? These are not easy things to consider, but consider them you must before permanently burning your bridges.

The postpartum tubal ligation has been popular for quite some time, either by next day surgery before the mother is discharged from the hospital, or immediately after removing the baby at the time of a C-section. This is another scary thought, because the riskiest time in any new baby's life is the first 48 hours. If some weird heart defect doesn't manifest itself till after a hasty tubal ligation, a mother can never predict what will go through her head if something were to happen to her baby and she's been rendered incapable of having another. True, the replacing the baby that's gone way of thinking is wrong, but there is some comfort psychologically if a woman knows she can try again. This is evident, actually, in reverse, when we see the pain in a couple who can't try again after such a tragedy. The sterilization can add additional anger to an already psychodynamically charged situation.

The reasons for permanent sterilization run from mere convenience to mortal danger from a subsequent pregnancy. There are those who will report that they became pregnant using condoms, oral contraceptives, or hormonal implants, and that permanent sterilization is the only option left. While it's true that responsible couples have actually thought this thing out well before asking for such a permanent change, there are always a few who need to know about their misconceptions or their casual reasoning. And any responsible doctor will make sure they've heard all of the worst things that can happen in life before agreeing to such a procedure.

(For the record, the absolute SAFEST method--cheapest, too--of permanent sterilization is vasectomy. It's done in doctor's office instead of a hospital or surgicenter. It uses a local anesthetic instead of a general anesthetic or epidural (or spinal). The recovery is ten times faster. And it doesn't involve entering a major body cavity like a tubal ligation does...unless, of course, you're a man, who always considers his scrotum a major body cavity.)

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