Q: I am pregnant with my fourth child and am considering getting a tubal ligation during a planned C-section delivery. Is this a good option, and need I worry about post tubal ligation syndrome?
A: If you are sure you will never want to bear another child, this is an excellent way to ensure future contraception. And no, it should not increase the complications of the delivery or affect your future health.
With this procedure, your surgeon blocks the fallopian tubes by removing a small portion and “tying off” the ends — in medical terms, ligation — so that eggs released cannot be fertilized by sperm. (The fallopian tube is the meeting place for egg and sperm. Only after fertilization and subsequent cell division is the embryo-to-be transported to the uterine cavity, where it attaches to the lining and continues to grow.)
Your C-section recovery will not be affected by the addition of a tubal ligation. A laparotomy (opening of the abdomen) and an incision in the uterus will already have been performed. Once the baby has been delivered, the surgeon will use the incision in the uterus to close the fallopian tubes (and, of course, will also close the abdominal incision).
Tubal ligation prolongs the length of the surgery by only a few minutes. You will not have more pain or bleeding, nor should the chance of infection increase.
(Women who undergo a vaginal delivery and want a postpartum tubal ligation will have to undergo abdominal surgery, in which a small incision is made beneath the belly button to access the tubes, which are located near the top of the enlarged uterus. This additional surgery will increase postdelivery healing time and discomfort.)
There has been considerable discussion and negative press given to so-called post tubal ligation syndrome: irregular periods, cramps, PMS, hormonal changes and even early menopause. Most doctors don’t think this syndrome exists.
It’s true that women who have been on birth-control pills or have been pregnant often (and, along with breastfeeding, have experienced few menstrual periods) may develop troublesome cycles and hormonal changes once they stop taking oral contraception or cease being pregnant. But this is due to the unmasking of their real hormonal condition and has nothing to do with their tubal ligation.
The only time ovarian function might theoretically be affected by the ligation procedure is if the vessels supplying blood to the ovary were damaged. This is a highly unlikely occurrence during a C-section or after a delivery.
You may wonder what happens to the egg if it is “stuck” in a closed portion of the tube and unable to run its full tubal course into the uterine cavity. Is it akin to a chicken egg laying freely within the abdomen with no place to go?
No! The egg is basically a microscopic cell that, without fertilization, will degenerate and disappear, as millions of other cells in our bodies do every day. Even in the absence of a tubal ligation, most eggs never get fertilized but instead wither away in the ovary. So you needn’t worry about egg buildup.
A tubal ligation is considered a fail-safe method of permanent contraception — or at least we used to think so. But recent studies have shown that of all women who have tubal ligations (done either at the time of C-section, immediately after a vaginal delivery or at another time through a laparoscopic procedure), 2 percent will get pregnant within 10 years.
This seems surprising, but in rare situations the tube may not be fully closed off, so it reconnects and again allows sperm to meet egg. This is highly unlikely, but I mention it so that you will get a pregnancy test if you unexpectedly miss a period. If positive, you will need an ultrasound to make sure the pregnancy is not stuck in the tube, where it can eventually rupture.
Beyond the medical issues, though, you must really think whether you want this procedure in the first place. You are making a decision based on the fact that you expect you and your husband to raise four healthy children. There are, unfortunately, no guarantees that tragedy will never strike or that the family situation won’t change.
So the decision to go with permanent contraception must be well-considered and not made in the midst of labor pains, when it’s quite natural to conclude “I will never do this again!”
The biggest disadvantage of permanent contraception is the possibility of future regret. This has been found to be more common (up to 25 percent) among young women with few children.
But there are some health advantages to having a tubal ligation. It decreases the risk of ovarian cancer by one third, possibly by keeping cancer-causing contaminants from traveling from the vagina up through the uterus and tubes to the ovaries. Blocking the tubes also appears to keep out bacteria, diminishing pelvic inflammatory disease.
Dr. Reichman’s Bottom Line: If you are having an elective C-section and are absolutely sure you won’t want more children, tubal ligation is safe and effective.
Dr. Judith Reichman, the “Today” show's medical contributor on women's health, has practiced obstetrics and gynecology for more than 20 years. You will find many answers to your questions in her latest book, "Slow Your Clock Down: The Complete Guide to a Healthy, Younger You," published by William Morrow, a division of HarperCollins.