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Death: An Undeniable Risk of Tubal Ligation

April 7, 2015

tubal-ligation-and-deathIn the developed world tubal ligation and vasectomy are considered safe and effective procedures.

At some point, most will consider having a sterilization procedure to prevent unplanned pregnancy.

Most will focus on the immediate risks of the procedure.

Unfortunately the long-term risks are more serious.

Although both tubal ligation and vasectomy have risks, tubal ligation has more serious risks and, in some cases, can result in death.

Death from tubal ligation

Deaths directly due to tubal ligation are rare but possible.

In 2014, 13 women in India died from overwhelming infection after tubal ligation procedures. These cases were brought to worldwide attention and reinforced the risks of tubal ligation.

Deaths After Tubal Ligation in India

Although tempting to dismiss the sterilization deaths in India as a result of substandard health care in the developing world, death from tubal ligation also occurs in the United States.

Although likely ‘old and forgotten’ news, the Center for Disease Control (CDC) documented the deaths of 29 women associated with tubal ligation in the United States from 1977 to 1981. The majority of deaths were due to anesthesia complications and the remainders were directly attributable to complications related to surgery. The 29 deaths may be an underreported number and the actual number of deaths may have been as many as 108 women.

Tubal Ligation Deaths in the United States

Death from Essure sterilization

Essure sterilization is a newer method of tubal ligation for women. Essure sterilization can be performed in a doctor’s office using local anesthesia. Since 2001 this method has been performed on over 700,000 women in the United States.

Essure was initially considered safe and 100% effective based on clinical trials submitted to the FDA; however, with more widespread use Essure has been observed to be less than 100% effective and has caused some serious problems in women. Often these problems require major surgery to remove the Essure devices. Many women have had to have hysterectomy procedures to treat Essure complications.

Although considered a safer alternative to tubal ligation an adverse event report involving death from Essure was submitted to the FDA in 2015.

Most common risk of tubal ligation: Forgotten over time

The largest study on tubal ligation, U.S. Collaborative Review of Sterilization, indicates 1 out of every 54 tubal ligation procedures will fail and result in pregnancy.

Many tubal ligations failures will result in ectopic (in the fallopian tube) pregnancy. Despite the high failure rate, many ectopic pregnancies after tubal ligation are not recognized early because pregnancy is not suspected. When these pregnancies are allowed to grow within the tube they will often cause a rupture of the fallopian tube, internal bleeding, serious injury, and, in some cases, death.

A CDC analysis of female sterilization indicates:

“Ectopic pregnancy after tubal sterilization is not rare… Ectopic pregnancies are the leading cause of pregnancy-related deaths in the first trimester and account for 9% of all pregnancy-related deaths in this country.”

Although tempting to blame patients for not suspecting pregnancy early enough after tubal ligation, health care providers are also responsible. Recently there was a highly publicized story of a California woman who went into a coma after an undiagnosed ectopic pregnancy. These stories are common and often underreported. Most doctors in reproductive health care can cite personal experiences where ectopic pregnancies were not diagnosed until late resulting in serious patient injury.

Ectopic pregnancy is a major cause of morbidity (sickness) and mortality (death) in women who have tubal ligations. As the time from the tubal ligation increases the tendency is to associate the ectopic pregnancy less with the risk of tubal ligation and more with the ‘risk of being a woman’. As a result, the passage of time after tubal ligation can cause us to lose sight of a delayed risk of tubal ligation.

Vasectomy and chance of dying

There has only been one case of death after vasectomy reported in the medical literature:
Lethal Forunier’s gangrene following vasectomy.

In comparison to the one reported death due to vasectomy within the last 75 years how many deaths have there been from tubal ligation? We have just discussed 14 highly publicized tubal ligation deaths within the past 12 months.

Keeping the pressure on women: Will it ever change?

Although what constitutes an adverse outcome is often debatable, death is an unarguable adverse outcome. Vasectomy is much safer than tubal ligation.

Vasectomy is underutilized in the United States and most of the world. Unfortunately, vasectomy utilization will not increase any time soon because of the lack of mandated vasectomy coverage in the Affordable Care Act and the soon to be implemented public health experiment involving removal of the fallopian tubes as a treatment to prevent ovarian cancer.

ACA: Giving men even more of a reason to ‘tap out’ on vasectomy!

The Affordable Care Act, aka Obamacare, requires coverage for birth control and tubal ligation for women at no cost but does not require vasectomy coverage for men.

ObamaCare: Leaving Men Hanging on Vasectomy Coverage

If you want to increase the burden of sterilization on women and provide men with more of a reason not to have a vasectomy then do like the ACA and make tubal ligation free and vasectomy relatively more expensive. This is ‘great’ public health policy and goes a long way to promote reproductive fairness.

Fallopian tube removal: Public health trial at best

Although removal of the fallopian tubes for the prevention of ovarian cancer has theoretical promise and could be a major step in the prevention of ovarian cancer, some vocal leading women’s health care advocates are calling for immediate, wide-spread implementation of this procedure on women without adequate comparative trials. The language they use is the language of urgency… ‘Time is important’ and a proper study ‘Would take too long’. We seem not to have learned lessons from previous medical missteps (postmenopausal hormone replacement therapy, electronic fetal monitoring, etc.) that all began with good intentions.

An experimental widespread public health care trial of fallopian tube removal will have an impact of unknown significance on women’s health and a significant chilling effect on vasectomy utilization for a very long time.

Submitted by Dr. Charles Monteith

Dr Monteith is an Ob/Gyn and specialist in women’s health who provides tubal reversal, vasectomy reversal, and no-scalpel vasectomy in Raleigh, North Carolina.

For additional insight: Why Dr. Monteith performs vasectomy procedures?

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5 Responses to “Death: An Undeniable Risk of Tubal Ligation”

  1. Thanks, Dr. Monteith, for this summary of the evidence and indictment of the current state of reproductive coverage in the United States. As a primary care provider, I struggle with the failure of insurance to cover a vasectomy – a simple office procedure with minimal discomfort and recovery time, and the lowest risk to the family for future pregnancies and for procedural complications. But when my patient faces a $6000 deductible, as does a patient in whom I’ll be doing a vasectomy this week, it’s hard to justify the out of pocket expense when his insurance will pay for the $10,000 tubal ligation his wife can have at our local hospital.

    Michelle Schirch Shelly, M.D.
    Lincoln Avenue Family Medicine
    IU Health Goshen Physicians
    Goshen, IN USA

  2. We want social justice in reproductive health. Men should play a more greater role in family planning and relieve their partners some of the burden of contraceptive use.

    Dr. Charles Ochieng
    Medical Director Wispivas
    Nairobi, Kenya

    • Thanks Frohnie but the article also discusses death after tubal ligation in the United States from the more traditional tubal ligation methods as well as the newer sterilization methods, i.e. Essure. More importantly it discusses the seriousness of ectopic pregnancy as a risk of tubal ligation. This is a very serious problem for women who have tubal ligation failure. Admittedly in the developing world the benefits of tubal ligation are more substantial because maternal morbidity is so much higher…prevention of pregnancy saves more lives (mom and baby) than the lives lost as a result of tubal ligation surgery. As the developing world becomes more sophisticated and sees decreases in maternal morbidity then these countries will have to reevaluate the benefits of tubal ligation. When I have performed vasectomy in other countries it amazes me to see how many tubal ligation procedures are performed (I understand why and the importance) but it also scares me to wonder what it is like to have an ectopic pregnancy in a hut in Africa and have to walk 30 miles to the nearest hospital where you then have to pay for your care. I am the first to admit tubal ligation vs vasectomy is a complicated analysis in the developing world.

  3. I did not receive adequate counseling before making this dreadful decision. I wish that I could reverse this, and have a peace of mind. Thorough counseling from a certified Psychologist should be prescribed for the patient before any final decisions. I wish that someone could help me to heal by reversing the emotionally unwanted deed.

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