Laparoscopic Tubal Sterilization

Laparoscopic tubal sterilization is a set of surgical techniques that use laparoscopy to render people with female reproductive systems sterile, or unable to reproduce. In a laparoscopy, a surgeon uses small incisions in the abdomen to feed in a camera or other viewing tool that aids in diagnosing internal medical issues or treating those issues via surgery. To sterilize a patient, the surgeon uses a camera with attached surgical tools to guide the procedure and interfere with the fallopian tubes to stop the passage of an egg. Laparoscopic sterilization was developed as an alternative to surgical sterilization that requires larger incisions to open the abdomen to access the fallopian tubes, which can pose a greater risk of complications. Due to decades of technical development, laparoscopic tubal sterilization allows people with female reproductive systems to control their fertility more safely and less invasively than with other surgical methods.

1. Relevant Definitions and History of the Procedures
2. Undergoing Laparoscopic Tubal Sterilization
3. Potential Risks of the Procedure
4. Rates of Tubal Sterilization

Relevant Definitions and History of the Procedures

Laparoscopic tubal sterilization is the union of laparoscopy and tubal sterilization, two separately developed surgical procedures. Laparoscopy is a procedure that involves making a small cut through the anterior abdominal wall, or the front of the stomach, for the purpose of endoscopy. Endoscopy refers to any minimally invasive procedure with the goal of inserting optical equipment into a patient. Laparoscopy’s abdominal site of incision is what differentiates the procedure from other forms of endoscopy, such as culdoscopy, which involves an incision into the back of the vaginal canal, near the cervix. Laparoscopy came about as the result of physicians and medical researchers in Europe in the early twentieth century attempting to find diagnostic methods for abdominal health issues that did not involve making large surgical incisions into a patient.

Tubal methods of sterilization rely on interference with the fallopian tubes, which stops the passage of an egg through the tubes. Without an egg moving through the fallopian tube, where an egg typically meets and fuses with a sperm cell, a patient cannot become pregnant via sexual intercourse. There are a variety of methods to introduce blockage to the fallopian tubes including tying, tube removal, and burning. Tubal sterilization came into use during the late nineteenth century in the United States. Samuel Smith Lundgren, a physician in Toledo, Ohio, performed one of the first reported tubal sterilizations in 1880 using silk sutures to tie shut a patient’s fallopian tubes.

Laparoscopy initially evolved as a method of accessing the inside of the abdomen for diagnostic purposes before it became a method for surgical interventions such as tubal sterilization. Physicians and medical researchers have experimented with various ways of accessing the inside of the human body for millennia, but the forms of laparoscopy still present as of 2024 began with Georg Kelling, a surgeon who worked in Germany in the early twentieth century. In 1901, Kelling reported on the potential uses of laparoscopy, which he called coelioscopy at the time, on a human patient after he had performed an experimental laparoscopy on a dog. He pumped air into the dog’s abdomen and used a cystoscope, which, at the time, was a thin tube with a light and lens attached to it that, typically, physicians would feed into the urethra, or the tube that allows urine to leave the body, to examine the urinary tract. Kelling argued that laparoscopy could allow physicians to avoid performing more extensive surgeries to examine and diagnose internal medical issues. After Kelling’s work, physicians and researchers in Europe and the United States continued experimenting with diagnostic laparoscopy during the first decades of the twentieth century to better see inside the human body.

The laparoscopic approach to tubal sterilization emerged as physicians and researchers began to use laparoscopy as a means to perform surgical procedures in the 1930s, and researchers P. F. Bösch and Patrick Christopher Steptoe were two of the first to introduce that approach. The first reported surgical applications of laparoscopy, from Germany and the US, respectively, involved removing internal scar tissue and taking tissue samples from the liver. In 1936, Bösch, a surgeon working in Switzerland, published a report of the one of the first laparoscopic tubal sterilizations. After further refinements and applications to various surgeries during the following decades, Steptoe, a physician working in the United Kingdom who focused on the female reproductive system, published a paper in 1965 in support of laparoscopy. Steptoe argued that laparoscopy was a valuable tool for surgeons focusing on gynecological procedures, particularly for treating endometriosis, ovarian cysts, and ectopic pregnancies. Endometriosis is a medical condition where the tissue that lines the uterus, which is the organ where a fetus develops, grows outside the uterus, typically causing the individual chronic pain. Ovarian cysts are fluid-filled sacs that grow on the ovaries, or the organ that carries egg cells, and ectopic pregnancies occur when the fertilized egg abnormally implants outside of the uterus. By the mid-1960s, Steptoe had performed over 100 laparoscopies for various purposes, and he published Laparoscopy in Gynaecology, a textbook focused on the method, in 1967. In the second half of the 1960s, Steptoe began using laparoscopy to perform tubal sterilization procedures on patients seeking permanent birth control.

Laparoscopic tubal sterilization, and endoscopy in general, began to incorporate video technology in the later part of the twentieth century, with surgical teams beginning to use small video cameras in 1987. Screening the video feed from inside the patient allowed an entire surgical team to view the procedure instead of only the main surgeon looking through a single eyepiece. Developments in the twenty-first century have primarily involved improving the video display during surgery as well as robotic assistance with certain laparoscopic procedures.

Undergoing Laparoscopic Tubal Sterilization

To prepare for a laparoscopic tubal sterilization procedure, the medical team performing the surgery must properly orient, examine, and anesthetize the patient. The surgeon can direct the patient to lie horizontally with their legs held up by stirrups. Once positioned, the surgeon examines the lower abdomen to determine the position and size of the uterus and the approximate locations of the surgical sites. Once the examination is complete, the surgeon places the patient under some level of anesthesia. Often, patients undergo general anesthesia, leaving them unconscious for the entire procedure. In some cases, the surgeon only numbs the area of operation, leaving the patient either fully awake or mildly sedated.

Once the surgeon has properly anesthetized the patient, the procedure can begin. The medical team tilts the operating bed or table back at a slight angle, which raises the patient’s lower half for the procedure. After disinfecting the patient’s stomach area, the surgeon makes a small incision into the abdomen, typically in or around the navel, and pulls the incision open. Pulling the incision farther open creates space between the patient’s abdominal wall and the organs underneath. The surgeon inserts a needle connected to a tube into the incision. The tube’s other end connects to a specialized air pump called an insufflator. The medical team uses the insufflator to pump gas, typically carbon dioxide or treated air, into the space between the abdominal wall and the internal organs, effectively inflating the patient’s inner abdomen. Often, according to the Government of India’s Reference Manual for Female Sterilization, when the surgeon can tap the patient’s abdomen and hear a sound like a drum, there is enough gas pressure inside the abdomen to proceed with the surgery.

After using the insufflator to pump gas into the patient’s abdomen, the surgeon and team can insert the tools necessary for the sterilization. To maintain adequate gas pressure during the procedure, the surgeon uses a trocar, a specialized, large needle with a stopcock that connects to the insufflator. The trocar, inserted into the abdominal incision, keeps the incision open wide enough to feed in other equipment. The surgeon also inserts the laparoscope, the camera that allows the medical team to see the patient’s organs, into the abdomen through the trocar, along with any connected surgical equipment. The surgeon feeds the laparoscope through the trocar and begins maneuvering it toward the pelvic organs. To ascertain the laparoscope’s orientation and position inside the patient, the surgeon can inspect and identify the organs and other structures of the pelvic cavity. By using various anatomical landmarks, the surgeon can tell where specifically the surgical equipment is inside the patient.

While the laparoscopy procedure allows the surgeon to access the fallopian tubes, the particular method of tubal sterilization performed thereafter is up to the preference of the surgeon and patient, and one of those common methods is electrocoagulation. Electrocoagulation is a procedure in which the surgeon blocks the passage of an egg through the fallopian tube by passing an electrical current through the tissue of the tube. The electrical current burns the tube, and the resulting tissue damage renders the tube unable to pass an egg through it. There are two main methods of electrocoagulation. The unipolar method uses one electrode, and the electrical current passes out through the patient’s body. The bipolar method uses a clamp where each of the two grasping arms functions as an electrode. Using two electrodes helps to avoid possible unwanted damage from the electrical current, such as intestinal burning associated with the unipolar method.

Aside from electrical methods, laparoscopic tubal sterilization often involves implants such as silastic rings and mechanical clips. Silastic rings typically consist of silicone rubber and have a diameter of one millimeter. To apply a silastic ring, a surgeon uses a grasping tool to grab a point on the fallopian tube between 2.5 and three centimeters away from where the tube meets the uterus. The surgeon then pulls to create an arch in the tube and uses an applicator attached to the laparoscope to fit the silastic ring over that arched portion of the tube, pinching it shut at two points. Mechanical clips, typically made of plastic or titanium, clamp around the fallopian tube at a single point, blocking the passage of an egg. One of the possible concerns when using a mechanical clip is that the pressure from the clip may be insufficient to keep the fallopian tube blocked if the tube’s tissue degrades over time. To offset that risk, the clips in use as of 2024 contain metal springs or silicone rubber surfaces that provide consistent pressure regardless of any changes to the fallopian tube.

After the surgeon has applied the chosen sterilization method to block the passage of an egg through both fallopian tubes, the medical staff can remove the surgical equipment and finish the procedure. The surgical staff orients the operating table into a horizontal position and removes the laparoscope, along with any connected surgical tools, by pulling it out through the trocar. Once the laparoscope is no longer inside the patient, the staff can disconnect the trocar from the insufflator and leave its valve open, which allows the gas inside the patient’s abdomen to slowly release. The surgical staff can remove the trocar from the incision and suture the incision closed. The staff also often provides some sort of bandage or dressing for the sutured incision. After the procedure, the patient should rest for two days, after which light physical activity is acceptable. At one week after the procedure, the patient can engage in any level of physical activity. Follow-up appointments can allow physicians to ensure that the patient is recovering properly from the surgery and that there are no complications.

Potential Risks of the Procedure

Complications due to laparoscopic tubal sterilization primarily involve unintended damage to the organs and tissues of the abdomen, though they only occur in a minority of cases. Another possible and more serious complication that can occur after the operation is ectopic pregnancy, where an embryo, or fertilized egg, implants somewhere other than the uterus, such as the fallopian tubes. Most ectopic pregnancies, if untreated, result in the death of the embryo and the person carrying it because an embryo cannot properly grow anywhere outside the uterus. A 1997 study of over 10,000 tubal sterilization patients indicated that tubal sterilization, both laparoscopic and not, did not rule out the possibility of ectopic pregnancy. Additionally, in cases where the sterilization failed, the resulting pregnancy had a higher risk of being ectopic. The American College of Obstetricians and Gynecologists, the professional organization that oversees the physicians who typically perform laparoscopic tubal sterilizations, reports that the procedure has an overall low risk of complications.

Rates of Tubal Sterilization

Tubal sterilization, regardless of method, is one of the most common forms of contraception in the US as of 2024, with hundreds of thousands of people undergoing the procedure every year. The procedure is generally successful, with failure rates not often larger than two percent. In a 2010 study published in the journal Fertility and Sterility, Lolita M. Chan and Carolyn L. Westhoff, researchers affiliated with the Department of Obstetrics and Gynecology at the Columbia University Medical Center in New York City, New York, estimated that 643,000 patients had undergone tubal sterilization in 2006. Laparoscopic approaches to tubal sterilization tend to see more usage in interval procedures, which are sterilizations that do not occur immediately after giving birth. Within laparoscopic tubal sterilization, bipolar coagulation is one of the more common methods. Chan and Westhoff identify an increase in tubal sterilization throughout the final three decades of the twentieth century, which they attribute to an increase in the use of laparoscopic methods, as such methods allow for outpatient procedures.

As of 2024, due to laws and regulations imposed on women’s reproductive and abortion rights, the rate of tubal sterilization procedures in young adults between eighteen and thirty years of age has increased in the United States. In 2022, the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization (2022) overturned the constitutional right to abortion set in place by Roe v. Wade (1973). That decision in 2022 permitted states to restrict or ban abortion care. Researchers from Boston University in Boston, Massachusetts, and the University of Pittsburgh in Pittsburgh, Pennsylvania, report that the decision resulted in an abrupt increase of permanent contraceptive use, including tubal sterilization.

As of 2024, many people continue to choose to undergo laparoscopic tubal sterilization to control their fertility. The procedure serves as an alternative to more radical abdominal surgery and allows people to obtain permanent sterilization with a short and easy recovery.