Permanent contraception procedures: vasectomy vs. tubal ligation

People make decisions about permanent birth control for themselves and their future. Choosing the right path as a couple or individual might feel stressful, and experts with Baylor College of Medicine help outline the decisions to get a vasectomy or tubal ligation.

What is a vasectomy?

A vasectomy is a permanent contraception procedure for men in which a surgeon ties off or cuts the tube that delivers sperm to the seminal fluid. The minimally invasive procedure takes about 10 to 15 minutes with minimal pain due to a scalpel technique, which involves no incision.

Vasectomies are typically an outpatient procedure with a quick recovery. Avoid heavy lifting, strenuous exercise and ejaculation for seven days post-op. Protected intercourse is required for up to three months to avoid conception. After three months, you receive a semen analysis, and if there is no motile sperm or less than 100,000 sperm noted that are not motile, you are considered clear from the vasectomy, and it was successful.

“If a patient has motile sperm for 6 months, it would be considered a failed vasectomy and should consider redoing the vasectomy,” said Dr. Mohit Khera, professor and F. Brantley Scott Chair in the Scott Department of Urology at Baylor.

What is tubal ligation?

Tubal ligation is a permanent sterilization procedure for women in which a surgeon cuts the fallopian tube on both sides. There are two commons forms:

• Mini laparotomy after vaginal delivery: about a 2 to 3 cm incision that can be done the same day or day after a vaginal delivery. Patients can go home after one or two days, followed by a six-week recovery.
• Laparoscopic approach (salpingectomy), which is becoming more common: two or three small 5 mm incisions in which the patient is sent home the same day, also followed by a six-week recovery.

With either procedure, patients should feel better after a few days to a week and should not have significant pain.

“The main thing we worry about is complications with the incision or healing of the abdominal wall,” said Dr. Matthew Carroll, assistant professor of obstetrics and gynecology at Baylor. “In general, even after an uncomplicated vaginal delivery, we tell folks to avoid lifting anything heavier than the baby or a gallon of milk – about 15 to 20.”

Risks

Both vasectomies and tubal ligations/salpingectomies are generally low-risk procedures. Bleeding, infection or pain can occur as a result of vasectomy, but the risks are less than 1 to 2%. Khera recommends urologists carefully counsel certain patients, such as young men who are more likely to change their mind or one who has a guardian due to impaired mental capacity. Those on blood thinners must stop taking their blood thinners before getting a vasectomy.

“There are times when the anatomy is such that it may make more sense to do the vasectomy in the operating room as opposed to the clinic because they have a tight scrotum or varicocele,” Khera said.

Those who have had vaginal deliveries, no abdominal surgery or has nothing that should lead to scar tissue around the uterus or fallopian tube should be good candidates for tubal ligation. It should be easy for the surgeon to pull up fallopian tubes either immediately after vaginal delivery or laparoscopically.

“Everyone has certain risks, but in general, laparoscopy is safe, but there are major important blood vessels nearby – bowels, intestines and bladder – so there is always a risk in having to make a larger incision to control any complications, but in general, it’s one of the lowest-risk procedures we do,” Carroll said.

For immediate postpartum people who delivered preterm, it can be harder to get to the uterus, so they might not be good candidates for tubal ligation. People who have had multiple surgeries, especially around the belly button area, should avoid it as well. If the surgeon cannot feel the top of the uterus and they cannot access it, those patients should not get a tubal ligation.

Reversal

Vasectomy reversal is common, but the longer a patient waits from the time of vasectomy to reversal can make it more challenging. Success rates decrease the longer they wait. The reversal is more invasive and takes more time than a regular vasectomy at around three to four hours.

A tubal ligation can be undone, and the reversal surgery takes longer. It also is less likely to be successful.

“I tell patients if they’re thinking about a tubal ligation, they really should plan for it to be permanent and not assume they can get it reversed if they want another baby,” Carroll said.

Efficacy

Vasectomies have an extremely low failure rate at roughly one in 2,000. While this is low, failure can lead to pregnancy. Vasectomy is minimally invasive and has one of the highest success rates for permanent contraception in men.

Testosterone therapy shuts down men’s sperm production. Testosterone should not be used as a form of contraception, but many men who take it are infertile.

Three out of 1,000 women have a chance of getting pregnant after tubal ligation. The tubes can grow back together, especially if the surgeon does not get a big enough piece, but this is very rare. Many surgeons, including Carroll, do bilateral salpingectomy for a variety of reasons, including risk of failure.

If a woman does get pregnant, they have a higher change of having an ectopic pregnancy, but if that embryo makes it to the uterus and implants normally, it could be a normal pregnancy since it overcame the main barrier in that woman’s anatomy.

“If you’re a low-risk candidate, it’s a low-risk procedure,” Carroll said. “Because we go in intraperitoneally, there are really important structures nearby, and those one in 1 million cases or for patients who are higher risk, I think it would be lower risk for their partners to get a vasectomy, but both are great procedures.”

By Homa Warren