Tubal Ligation Methods and Probability of Success
Tubal ligation is a common method of female birth control usually referred to a “tying or cutting” the fallopian tubes. Most women who choose tubal ligation feel their families are complete and foresee no additional children in their futures.
Many women, who underwent ligation, seek to have the procedure reversed because of changes in their lives. They may remarry after a divorce or their first spouse may be deceased and their new husband wants children. Some couples decide to have additional children after a change in financial status, the death of a child, or many other personal reasons.
While tubal ligation should be considered “permanent” when making the decision to not have further children, in reality it is often reversible or IVF can an effective treatment. See our Web page on tubal reversal for a thorough discussion of the many factors that influence the success of tubal reversal surgery.
During a normal reproductive cycle, the eggs travel from the ovaries through the fallopian tubes, where fertilization takes place, and into the uterus. Blockage of the tubes interrupts egg transport resulting in infertility.
How are the Tubes Cut/Blocked?
There are many methods for tubal ligation including laparoscopic methods to burn (cautery), clip (Hulka or Filshie clip), cut and remove a section of fallopian tube, band (Falope Ring - small thick rubber band that strangulates the tissue), removal of the distal end of the tube (Krohner fimbriectomy), or complete removal of the fallopian tube (salpingectomy). Tubal ligation is often performed immediately after delivery while still in the hospital using mini-laparotomy (a small incision just below the umbilicus [belly button]) or at the time of a cesarean section to remove a small portion of the tube (partial salpingectomy). The type of ligation has a direct effect on tubal reversal success rates.
Laparoscopy is the preferred surgical method for tubal ligation if it is not done at the time of delivery of a baby. Laparoscopy requires two (and sometimes three or four) small openings in the abdominal area be created, one at the pubic hair line, and one at the umbilicus. The laparoscope is a “telescope like device” that is inserted through the umbilicus and the operative tools are manipulated through the other openings. It is an outpatient procedure, recovery is quicker than “open” surgeries, and there is very little pain.
Some newer methods of tubal blockage for sterilization, such as the Adiana and Essure methods, do not require abdominal surgery and can be completed in the outpatient office setting using a hysteroscope “telescope like device” that is inserted through the vagina and cervix into the uterus. The Adiana or Essure device is placed in the proximal portion of the fallopian tubes and with time results in scarring and blockage.
There are many different ways the tubes can be “cut or blocked” and the type of procedure performed can influence the success of a future tubal reversal. Several of the more common tubal ligation methods are discussed below.
The Pomeroy Method
The Pomeroy method of tubal ligation is taught at most ob/gyn residency programs and is one of the most commonly performed. The tube is lifted and a loop is made with a ligature(similar to a string) to “tie off” the bottom of the loop. The loop created by the tube is removed leaving the two ends of the tube above the ligature.
The body tissue grows over and covers the tubal openings and the ligature dissolves leaving two closed separated sections of the tube. Since this procedure leaves healthy tubal tissue it can often be reversed. However, often the area between the isthmic (narrow proximal muscular portion of the tube) and the ampullary (larger, less muscular distal portion of the tube) is damaged making surgical reversal more technically difficult due to the disparity of the size of the proximal and distal tubal lumen that needs to be connected. There may be an increased risk for ectopic pregnancy after tubal reversal in these types of cases.
Both ends of the tube (next to the ovary and next to the uterus) are cut at a length of 2 cm and the ends are tied. The remainingtube between the cuts is removed to reduce the risk of natural reconnection. The amount of tube removed determines the potential surgical reversibility of this method.
Often the area between the isthmic (narrow proximal muscular portion of the tube) and the ampullary (larger, less muscular distal portion of the tube) is damaged making surgical reversal more technically difficult due to the disparity of the size of the proximal and distal tubal lumen that needs to be connected. There may be an increased risk for ectopic pregnancy after tubal reversal in these types of cases.
Clips and rings (bands) can be used to block the tubes. The procedure is usually done laparoscopically but sometimes a larger incision is required to place the clips. Clips or bands can also be placed at the time of cesarean section.
The Hulka clip is made from a soft pliable plastic known as Silastic. The Silastic clip is “spring loaded” and clips to the fallopian tube. Clips cannot be simply “unclipped” to open the tubes as they damage the tubal tissue. Surgical reversal with tubal reconnection is necessary. The Hulka clip has the advantage of causing the least damage to the fallopian tube (if only 1 clip is placed) and may therefore be the easiest to reverse.
The Filshie Clip is a small titanium clip with a soft Silastic lining. The clip clamps on the tube maintaining pressure resulting in immediate tubal blockage. Tubal tissue around the clip site eventually becomes necrotic (dies). If only 1 clip is placed on each proximal tube, tubal reversal is often an option in these cases.
Falope Ring Band
There are several tubal ligation “bands” available. The tube is formed into a loop and the silicon ring band is placed at the bottom of the loop. The banded area becomes necrotic causing tubal blockage. If only one band is placed on each tube, tubal reversal is often an option in these cases.
The Adiana Method
The Adiana method works by stimulating the body's own tissue to grow in and around tiny, soft inserts that are placed inside the fallopian tubes. The Adiana method does not require abdominal surgery.>
A hysteroscope is inserted through the vagina, cervix and into the uterus. A catheter is then inserted through the hysteroscope and into the proximal fallopian tube. A small amount of heat energy is delivered to create a lesion in the proximal portion of the tubes.
A small soft insert is placed in each tube at the site of the lesion. New tissue grows around the inserts thus blocking the tubes. It requires about 3 months for the tubal blockage to form. Tubal reversal surgery (implantation) is difficult due to the blockage of the fallopian tube in the muscular proximal portion of the tube.
For reversal, damaged portion of the tube must be cut out of the wall of the uterus and the tube must be implanted into the uterus. Pregnancy rates are expected to much lower for this type of tubal reversal surgery. IVF is recommended in these cases.
The Essure Method
Like the Adiana method, no abdominal surgery is required with the Essure method. Using a hysteroscope the physician has inserted through the vagina, cervix, and into the uterus, the device is inserted into the tubal opening and proximal part of the fallopian tubes.
A small portion of the metal tip of each insert remains visible inside the corner of the uterine cavity providing confirmation of proper placement. The inserts are made using silicone-free material that is used in heart stents, so they bend and conform to the shape of the fallopian tubes.
Tubal reversal surgery is very difficult due to the blockage of the fallopian tube in the muscular proximal portion of the tube. Reimplantation of the tube is required for surgical reversal which results in much lower success rates compared to other types of tubal reversal. IVF is recommended over tubal reversal in these cases.
This technique involves cutting the distal end of the tube and the fimbria. The fimbriae are fingerlike projections that collect the eggs. Tubal reversal has a very low chance for success due to the lack of fimbria. IVF is recommended in these cases.
Electrocautery, has the potential for extensive damage to the tubes making future tubal reversal unlikely to succeed. A long “tweezer like” device with two jaws is used to grasp the tubes. Electric current is passed between the jaws, and through the tubes, cauterizing (burning) between 1 and 3 cm of the tube. This process seals (scars) the tubes preventing the passage of eggs and sperm.
The potential reversibility of this method depends on the amount of tube that is damaged. Some physicians cauterize a single area, but most physicians cauterize multiple areas resulting in too much tube being damaged for reversal. IVF is usually recommended in these cases unless the operative report specifically describes a minimal amount of tubal cautery in a single spot.