TUBAL LIGATION
Tubal ligation- also called TL, is a permanent method of contraception for women. A woman who does not wish to conceive, can undergo a TL at any age after maturity. It is usually done on both fallopian tubes, and is known as bilateral tubal ligation (or BTL).
The fallopian tube refers to either of a pair of tubes, through which the mature eggs or ova of a female travel from the ovaries to the uterus. Fallopian tubes are also known as uterine oviducts, because they are the ducts through which ova pass.
The name tubal ligation is derived from the words ‘tube’ (as in fallopian tube) and ‘ligate’ (to tie up). The procedure involves tying up (ligating) the fallopian tubes, using a ligature (a cord or clip used in surgery to tie up a structure).
Accessing the fallopian tubes for a TL
Timing of a TL is important, as certain factors can reduce both the costs and time spent on the operation. There are several circumstances under which TL can be undertaken:
During a Caesarean section:
There are two reasons why a woman would want TL undertaken during a C-section. One is upon the advice of a doctor that it would not be safe for, “the woman to conceive again, especially after multiple C-sections. The second is when the woman has decided before the C-section that she does not want to have any more children (at least in the foreseeable future), and would like a permanent contraceptive solution.
Planned TL:
This can be undertaken immediately after a natural delivery, called postpartum TL, or at a time of choice the woman decides. In such a case; access to the fallopian tube can be done through mini-laparotomy; a small incision near the upper part of the uterus and laparoscopy. This refers to the examination of the interior of the abdomen using a laparoscope, a fibre-optic (thin and flexible) instrument with a tiny microscope.It is inserted into the site through the abdominal wall after a small incision is made through the skin and abdominal wall. The instrument not only views the inside but it is also used to perform minor surgeries. A laparoscopic procedure is safe but expensive.
When is the right time for a TL to be done?
The best time to get TL done, is when you have achieved your desired family size. It should first and foremost be your decision. Secondly your partner needs to concur with that decision. The TL may be done at a convenient time-during delivery in the event of a planned C-section, when a patient has been counselled and signed the consent forms. It can be performed a day or two after normal delivery, carried out several weeks after a normal delivery, or at your own time.
Other reasons include:
- When you have had three C-sections, and permanent contraception is advised by the doctor.
- When you have had a complication that led to major repair of your uterus, for instance, a raptured uterus, and you already have the number of children, you desire.
- In certain ‘special circumstances’ a medical practitioner is allowed to decide to ligate the fallopian tubes, and then inform the patient later. This occurs where the condition of the patient, would not have allowed her the opportunity to accede to the decision. For instance, in the event of a coma. In such rare cases, the doctor will explain the compelling reasons for the decision. This may include a clear diagnosis; that your uterus cannot sustain another pregnancy.
How is TL done?
The operation can be done under general anaesthesia (whole body), or local anaesthesia of the specific region of the body being operated on. Local anaesthesia is preferred, because the anaesthesia can be instilled up to the fallopian tube to numb it, and therefore the patient will not feel any pain during the operation. Local anaesthesia is also cheaper and safer.
A small opening of 2 centimetres is made near the umbilicus. A scalpel (knife with a small sharp blade), is used to make the incision under sterile conditions, preferably in theatre. Once the fallopian tubes have been accessed, clips, pads or cords are then used to tie the tubes. The grip must be tight enough, for the TL to be successful.
This is especially the case in laparascopy.
What is the success rate of TL?
The success rate differs, depending on the type of procedure chosen for the TL- and the timing of surgery. TL done immediately after a Caesarean-section tends to have a higher failure rate, than interval TL (more than 6 weeks after delivery). In general, however, TL is highly effective with overall failure rates being less than 1 %.
Why does TL fail?
Errors in operation:
When the person carrying out the operation picks the wrong structure, failure is imminent. As a precaution, a surgeon must see the end of the fallopian tube to be sure she is operating on the correct organ. This is because there are other structures nearby, that look almost like fallopian tubes.
Recanalisation:
Failure can also occur as a result of recanalization. This is a natural recombination and reconstitution of the fallopian tubes, when the separated tubes are too close to each other.
Wrong timing:
If performed late in the menstrual cycle, an undetected pregnancy may already be developing (luteal phase pregnancy), which continues to develop after the surgery.
What happens if a TL operation fails?
First, pregnancy may occur and the patient is counselled and advised to carry the pregnancy to term. If the failure is occasioned by a medical condition, one is allowed by law on medical justification to procure an abortion.
Can TL be attempted again if the first fails?
A patient has the option of having the operation again. If the operation is carried out by another surgeon, or in another medical institution the patient must disclose details of the previous operation, to enable proper diagnosis and decision-making by the doctor.
Can TL be reversed?
An operation to reverse TL is called anastomosis, a procedure that surgically connects vessels or channels of body organs. It is a major operation where a doctor opens up the abdomen, and then reconnects the tubes. Such procedures are expensive, and do not offer a guarantee that one can sustain a pregnancy; subsequent pregnancies may be ectopic.
Factors affecting the success of the reversal include; the type of TL done and how the initial procedure was undertaken. The success rate of reversing a TL is highest where clips or pads were used, to block the tubes. The probability of resumption of fertility can be up to 60 percent where tubal destruction is minimal.
Can anastomosis fail if too much time has elapsed since the TL?
The fallopian tubes cannot fail to recombine and reconstitute, just because a woman stayed for many years with a ligated tube before opting to reverse the TL. However, the success of reversal tends to be higher if done sooner after the TL.
Issues associated with TL reversal
- The risk of getting an ectopic pregnancy
- Failure of the procedure, and therefore failure to achieve pregnancy
- Sometimes post-operative complications may present, such as adhesions. This is an abnormal attachment of organ surfaces in the pelvis, due to inflammation or injury
- One may also risk sustaining injuries during anastomosis.
What are the potential complications of TL?
The immediate complication is bleeding, when a vessel is cut accidentally.
The operating instruments can injure (puncture) the intestines, some parts of the ovaries, or injure a part of the uterus. Any scratch on the uterus makes it bleed because of its rich blood distribution.
Infection can occur if the surgical equipment used, was not properly sterilised or if there is improper care of the wound.
Blood can accumulate inside the pelvis due to internal bleeding, leading to the formation of a clot in the abdominal cavity. Also when one has internal bleeding, the intestines, bladder and uterus can attach to each other through adhesion. When these organs or vessels get stuck together they cause pain and discomfort.
Can TL lead to death?
In very rare cases, do complications associated with a TL, lead to death. However, there have been cases where the person carrying out the operation, accidentally ligated a structure other than the fallopian tube, for instance the intestines or ureters (tubes which convey urine from the kidneys to the bladder). This could lead to very serious complications and possibly death.
END: PG 05 FEB-MAR 07/30-31