“My personal opinion is that the only time a tubal is preferable to LARCs [Long Acting Reversible Contraception] for someone who is done with childbearing is if it's done during a C-section, where it is a minor part of an otherwise major surgery,” she explained. “Otherwise, you expose someone to surgical risk without any improvement in efficacy, a higher risk of ectopic pregnancy [due to procedural failure], and the issue of regret … I genuinely believe that a tubal ligation is not the best option for contraception for most people.”
So how does it even work? As Rabkin notes, a tubal can be performed with very little trouble just after birth, especially during a C-section. In this case, a section of each of the easily accessible fallopian tubes is removed and the ends sealed, preventing eggs from traveling to the uterus. A similar procedure, called minilaparotomy, which is most often used after vaginal birth, involves raising the fallopian tubes to a small incision site in the abdomen in order to occlude them.
For women seeking sterilization outside of the delivery suite, a procedure called laparoscopy is the most common option: After pumping the abdomen full of gas, the physician will access the fallopian tubes through a small incision with a thin, lighted tube. Then the tubes can be ligated using a variety of clips, bands, or cuts. The only nonsurgical option for ligation is the Essure transcervical device, a method in which a doctor inserts a coil of stainless steel and other materials into each of the fallopian tubes, where, upon expanding, they stimulate tissue growth around the coil and, ultimately, result in blockage of the tubes.
All of these procedures are relatively safe—the death rate is 1 to 2 per 100,000 for all surgical methods, according to the 2008 review, and a 2000 study found that almost all complications were connected to other health factors, like obesity, and not the procedure itself. But ligation still comes with some small risk of infection, bleeding, and negative anesthesia reactions, not to mention the possibility that it may not even work. According to the Collaborative Review of Sterilization (CREST) study, the 10-year probability of pregnancy following a ligation is 18.5 per 1,000 procedures, about seven of which could be ectopic, depending on surgical method and age.
But do these potential complications explain why doctors are resistant to perform sterilization? After all, there are many elective surgeries that carry the same, if not greater, risks.
My first thought, like yours, I bet, was that doctor hesitance must have to do with malpractice. But though a patient could potentially sue for a “wrongful birth” if the sterilization fails, it’s far more difficult to litigate if what’s at issue is her regret over having the procedure in the first place. For a court to take such a claim seriously, the claimant would have to show that she did not give informed consent. Considering how seriously practitioners take pre-sterilization counseling (especially with this country’s fraught history of forced sterilization), not to mention the considerable amount of “thinking time” built into the process—Medicaid, for instance, requires a wait period of 30 days in addition to whatever time it takes to get on the surgery schedule—a successful suit isn’t likely.
But while it might be difficult to sue for regret, that doesn’t make the possibility of second thoughts any less real. According to analyses of the CREST data, there is a cumulative 12.7 percent probability that any woman would express regret within 14 years of sterilization. But for women under the age of 30 at the time of the procedure, there is a 20.3 percent cumulative probability that they would eventually want to take it all back (compared to only 5.9 percent in the older cohort). Of course, there are other factors that may predict regret, including partner/doctor pressure and disagreement among partners about the procedure. However, the CREST research shows that sterilization at a young age is the strongest predictor of regret. (Incidentally, this trend holds true with young men getting vasectomies.)
So what about reversal? We have the technology. But as Dr. Rabkin puts it, “It is probably going to be more invasive, not be covered by insurance, and not be likely to succeed.” While statistics vary (25 percent to 87 percent reversal success rates, depending on the ligation method and time since the original procedure), most women—even those who deeply regret their decision—do not actually get one: The 14-year cumulative probability of requesting information about a reversal is 14.3 percent (40.4 percent among women 18-24 at the time of sterilization), but only 1.1 percent of women will actually request the procedure. Post-tubal pregnancy is also possible by IVF, but, once in this territory, the chances of success are slim in inverse proportion to the heft of the medical bills.
So what many women experience as “discrimination” at their OB’s office, doctors seem to regard as protection against future emotional pain. But this raises the question of whether a medical professional has any business worrying about a patient’s hypothetical future feelings in the first place. Where you stand on this may depend on how you define “harm” in a medical sense; after all, a core tenet of medicine’s Hippocratic tradition is to do none. So what happens when a doctor considers regret—immediate or in the future—as harm? Is the physician who performed the ligation on a 24-year-old (knowing that there was some significant possibility that she would later regret her decision) responsible for her 35-year-old heartache?
Medical ethicists take this question very seriously. Philosopher Piers Benn and gynecologist Martin Lupton considered the issue in a 2005 paper, writing that one must first decide if so-called “lifestyle” surgeries fall under the purview of medicine, and, if so, should patient autonomy be respected, even when the doctor feels it’s not in that person’s best interest?
If autonomy is the issue, the idea to explore is that the putative late wish to be able to have children is more autonomous than the earlier wish never to have any, perhaps because we get more experienced and mature as we get older. Although this may sometimes be true, it will not always be. The fact that one wish comes later than another one does not make its fulfillment better for me, nor does it make it more autonomous. Rather, we simply face a judgment call based on the facts of the particular situation.
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Smash and Grab
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