TL: obstetrician clarifies all doubts
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Tubal ligation is a surgery for definitive voluntary sterilization. That is, the woman's fallopian tubes are tied or cut, preventing the egg and sperm are found - not making it possible thus a pregnancy.
A tubal ligation is a method of contraception chosen by many couples around the world, especially because of its effectiveness. A survey entitled Tubal intrapartum and range, showed that in the United States, it is estimated that one million tubal ligation procedures are performed annually, and half of them are carried out immediately after delivery.
Brazil is also one of the countries with high prevalence of tubal ligation. Also according to the survey, the data show that about 40% of married women are sterilized at the same time there has been an increase in the number of repentant women who end up seeking treatment in infertility services.
The gynecologist Prof.. Dra. Laura Osthoff, general director of the Women's Mariska Ribeiro Hospital, explains that, according to the Brazilian legislation on Family Planning, Law 9263, to be subjected to sterilization, the woman must be over 25 years or two children. "The achievement of Family Planning is required. Surgery may not be made at the time of delivery, unless the woman has some serious health problems or have made several caesareans "he says.
The point is that this repentance possible for women who do the tubal ligation great concern to the majority of health professionals, as not always treating reversal is possible and even when it is, pregnancy rates are limited.
Also read: 38 questions about contraceptive answered by gynecologists
According to Alfonso Massaguer, gynecologist and obstetrician specialist in human reproduction and director of Clinical Mother, despite what the law says, sterilization is indicated in restricted cases. "We do not direct the sterilization in young women. We note, incidentally, very little, because today there are many reversible methods that work well, and if the woman repents future, she can go back. The ligation is indicated only when no other same solution. And the woman should be informed about it, "he says.
Types of tubal ligation
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In general, tubal ligation or ligation surgery is voluntary for final sterilization. The woman's fallopian tubes are tied or cut, preventing the egg and sperm meet.
Massaguer explains that vaginal (hysteroscopic), laparoscopic and laparotomy are access paths for sterilization. Learn more about each of these types of sterilization:
1. Ligation laparotomy
Domingos Mantelli, gynecologist and obstetrician graduated from the Faculty of Medicine of the University of Santo Amaro (Unisa) and a graduate degree in medical residency in the field of gynecology and obstetrics, explains that the sterilization by laparotomy is done by opening the belly. "It is a cut in the stomach, like a cesarean section," he says.
When it comes to advantages and disadvantages should be considered which are more or less intrusive means. "The cutting is the most invasive, which is the laparotomy, and she has a higher risk of infection and pain in the postoperative period," says Mantelli.
2. Laparoscopic Tubal
It is done by laparoscopy. "There are approximately three holes in the abdominal region, which is made ligation" said Mantelli.
"Laparoscopy is less invasive (compared to laparotomy), made by video and faster recovery and less risk of infection," the gynecologist and obstetrician.
3. hysteroscopic ligation (blunt)
It is made vaginally, without any cutting. Laura explains that this method consists in placing a spring device form only 4 cm called Essure within the fallopian tube with a thin endoscope (called a hysteroscope) through the vaginal canal.
"The microimplant placed in each tube causes a natural reaction which causes it to close in three months. For this reason, during the first three months, the patient continues to use another form of contraception. After this period, it is performed pelvic imaging and confirmed the obstruction of the tubes is not the use of another contraceptive method needed most, "said the doctor.
By not requiring any cutting, the technique does not require hospitalization and can be performed without anesthesia or mild sedation. "It's a quick procedure, or hospital outpatient and minimally invasive. The placement lasts up to 10 minutes and the patient often can usually return to their activities, without rest, clearance or permits. It contains no drugs or hormones and is effective up to 99.8%, "says Laura.
The doctor points out that the method of contraception is permanent and irreversible. "So the couple or the woman who choose this method must be determined to have no more children. Already the contraindications are minimal, such as pregnant women, with some kind of infection, or change in the uterus to prevent the placement of the implants, "he says.
In the table below, Laura makes a comparison indicating that considers the main advantages of sterilization by hysteroscopy (Essure) compared to other methods.
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To Mantelli, it is difficult to speak simply of advantages and disadvantages, or indication. "You have to see every woman, the preferences of each, whether it has or not scar, technical quality for each one, if it has grip or not, whether you have endometriosis, whether you have fibroids. Everything will determine the access road to be able to do the procedure and, suddenly, the health plan covers one technique or another. Also tells the doctor's skill, if he knows do for a technique or another, "he said.
antenatal and post-operative female sterilization
Mantelli explains that care preoperatively are the same as any surgery: take the exams and see if the patient has surgical conditions for performing the method. "The basic examinations are preoperative blood count, coagulation, electrocardiogram, transvaginal ultrasound (for analysis of the uterus and ovarian structures) and may be even requested further examination the doctor deems it necessary," he says.
Alfonso Massaguer remember that in addition to all the tests, it is essential to check if the woman does not want to have more children. It should be fully aware that tubal ligation is a permanent method.
"By doing tubal ligation, and then repent to reverse, there is another surgery (reversal) or she will have to leave for fertilization. Then, sterilization is indicated for rare cases only when there is no other solution even. And the woman should be informed about it, "recalls Massaguer.
"And it should be highlighted that in many cases the woman regrets having made tubal ligation. For more than a reversal is possible, it is a complicated surgery and it can not succeed, "adds Massaguer.
Already care in the postoperative period, according to Domingos Mantelli, refer to the type of surgery, laparotomy, video or hystero. "Each has its degree of invasiveness, that is, which one is more invasive. Accordingly, it will be necessary degree of rest, getting a time without physical activity, sex without taking anti-inflammatories and antibiotics and, if necessary, analgesics, "he says.
Ligation during Cesarean
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But does the tubal ligation can / usually performed during cesarean section? This is a point that raises many questions among women.
Mantelli explains that usually is not recommended female sterilization during cesarean section. "Unless the woman decide it and record notarized at least 90 days before the childbirth occurs, because she has to have the power of discernment and be fully in decision-making," he said.
"A tubal ligation can also be done during caesarean section if the doctor feels that if this woman becomes pregnant again, will bring risk to your life," the gynecologist and obstetrician.
TL: 10 questions answered
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1. The sterilization ensures that I will not get pregnant?
"The sterilization does not guarantee that you will not get pregnant. The failure rate is approximately 0.5%, but there is the chance of spontaneous recanalization, ie, the tube returns to stick to, say, spontaneously and the woman can get pregnant. The failure rate is about the same as a contraceptive, "said Mantelli.
Laura remembers that there is no contraceptive method is 100% effective. "However, the sterilization technique of hysteroscopy is the safest method final, reaching 99.8% effective," he says.
2. Are there any side effects?
Mantelli points out that an effect of sterilization is that it can increase the amount of pelvic varicose veins, varicose veins which are the side of the uterus.
Massaguer explains that, generally, there are many side effects, since it is a relatively simple procedure. "But in some cases, can lead to early menopause. It is rare, but is a possible risk, "he says.
May still occur pelvic pain and irregular menstruation. Although the sterilization target the final sterilization of women, in some cases this may not occur but is rare.
In addition, a major risk is the woman regret it later, when you decide to want more children. For this, you need to think twice before choosing this option.
3. Tubal fattening?
No. "It's not correct to say that tubal ligation fattening because it does not affect the metabolism or any other factor that manages weight gain," said Laura.
4. It is possible to reverse tubal ligation?
Depending on the technique that was used to make the sterilization. "The sterilization technique of hysteroscopy is irreversible, if you want to get pregnant after the procedure the woman should perform IVF," explains Laura.
"Generally, sterilization is not reversible, however, depending on how it is made may be a small chance of being able to get pregnant," adds the doctor.
Massaguer points out that, even when possible, the reversal is complicated and can not succeed. "So much so that sterilization is a major source of demand for fertilization. Many women regret later. And the truth is that most women who have tubal ligation has no statement to make. There are many and repent ... If they had been informed in the past that would be done? "He says.
Mantelli explains that the reversal is done by a surgery for tubal recanalization. "An anastomosis is made, ie you reconnects and suture again this tube that was cut. But it said that there is not always successful outcome, "he adds.
5. You can make sterilization by the health plan?
According to Massaguer, yes. Provided there is medical indication for it.
6. You can make sterilization by SUS?
Massaguer says yes, if indicated.
Laura adds that hysteroscopic tubal ligation (blunt) has become popular because until recently was restricted to offices and private institutions. "Today the Essure can be found as an option in the Family Planning Program in major public hospitals in the country. Women or couples interested should go to a Basic Health Unit (BHU) and enroll in Family Planning Program, "he says.
7. Who is indicated tubal ligation?
According to the law, usually sterilization is indicated for women who wish to sterilization to have no more children. You have to be necessarily more than 25 years and / or two or more living children.
Massaguer remember, however, that is very restricted. "It is only indicated for women who do not want to ever get pregnant. But it should be aware that lifestyle changes that ideas change ... It is indicated, in a case where the pregnancy endangers a woman's life, but still, there are other reversible methods, "he says.
"So despite what the law says, it is best to avoid as much, and opt for tubal ligation only when it is the only option and the woman has full assurance that'll never want to get pregnant," says the gynecologist and obstetrician.
8. There are contraindications of tubal ligation?
To Massaguer, the contraindication is exactly the fact that, in general, irreversible. And chances are the woman regret later. "It's something very restricted because there are other options to prevent a possible pregnancy, this should never be the first choice of women," he says.
9. What tests must be done before the sterilization?
Mantelli explains that it is necessary to do all the basic exam preoperative complete blood count, coagulation, electrocardiogram, transvaginal ultrasound (for analysis of the uterus and ovarian structures) and any other examination that the doctor deems necessary.
10. How is the recovery of tubal ligation?
According to Mantelli, recovery is usually very quiet. "It is a surgery that operates in one day and the next he is discharged. It takes approximately a week of home rest to return to normal activities without any problem. The restriction of physical activity is for about 20 to 30 days, "he says.
X ligation vasectomy
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Both are surgical and permanent contraceptive methods. Laura explains that the tubal ligation, performed in women, is done by blocking or cutting the fallopian tubes preventing the meeting of egg and sperm.
"In men, the vasectomy is performed by ligation or cutting the vas deferens, which prevents the presence of sperm in the ejaculate fluid," says Laura.
The doctor adds that "the statement of male and female permanent contraception should be based on strict criteria, in compliance with current legislation."
A vasectomy is reversible, but the reversal surgery is delicate. Likewise as the reversal of sterilization (if possible). Thus, the recommendation is that the woman who decides to tubal ligation and vasectomy man who decides to not think of a possible reversal. Otherwise, it shows that they probably are not prepared.
Other contraceptive methods
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In general, the sterilization should be a last resort for women. There are other reliable contraceptive methods and not definitive. Below you know the key:
IUD (intrauterine device): device to be inserted by a physician into the uterus. It is made of copper and has no type of hormone. Prevents the penetration and passage of sperm, not allowing his meeting with the egg. It has high efficiency (99.4%) and, in general, promises to protect women for 5 years. Method does not replace the condom because it does not prevent sexually transmitted diseases.
Hormonal IUDs: It is also an intrauterine device that prevents the penetration and passage of spermatozoa. Releases a hormone into the uterus and therefore, in addition to the contraceptive effect, other effects may have, for example reduction of menstrual flow. It has high efficiency (99.8%) and, in general, promises to protect women for 5 years. Method does not replace the condom because it does not prevent sexually transmitted diseases.
Pill: is a tablet that uses combination of hormones, usually synthetic estrogen and progestogen which inhibits ovulation. It also modifies the cervical mucus, making it hostile to sperm. The method is managed by the woman orally daily and, in general, has high efficiency (99.7%). It does not replace the use of condoms, it does not protect against sexually transmitted diseases.
injectable contraceptive: injection of hormones that inhibit ovulation and increases the thickness of the woman's cervical mucus, making it difficult the arrival of sperm into the egg and thus preventing pregnancy. The method may be monthly (effectively 99.9%) or quarter (99.7% efficacy). Method does not replace the condom because it does not prevent sexually transmitted diseases.
implant: a small stick (4 cm length) is implanted under the skin, preventing ovulation, it gradually releases progestogen dose. If used properly, the efficiency is 99.9%. It should be changed every three years. It does not replace the use of condoms, it does not protect against sexually transmitted diseases.
The vaginal ring: It is a small ring of silicone, with about 5.5 cm diameter. It combines estrogen and progestogen which are released continuously when the ring is inserted into the vagina. If used properly, the efficiency is 99.7%. It must be placed once a month. It does not replace the use of condoms, it does not protect against sexually transmitted diseases.
adhesive: It is a thin adhesive, 4.5 cm x 4.5 cm which combines estrogen and progestin, hormones that are absorbed by the body and prevent ovulation. Should be pasted on the skin of the arm, back, groin or buttocks. If used correctly, it has efficiency of 99.7%. It should be added once a week. It does not replace the use of condoms, it does not protect against sexually transmitted diseases.
male condom: barrier method, well known. The condom is made of thin, flexible and resilient latex, and may be used as a "protective cover" the penis. If used correctly, it has 98% effectiveness. It shall be used throughout intercourse. Still protects against sexually transmitted diseases.
Female condom: prevents contact between the skin of the penis and vagina, thus preventing the spread of sexually transmitted diseases and preventing the egg from being fertilized. It shall be used throughout intercourse. And the effectiveness when used correctly, is 98%.
Diaphragm: It is a dome made of silicon or latex, with firm and flexible edges. It must be placed within the vagina. It has different sizes, between 6-8 cm, so it's important to talk to the gynecologist to find out what is the ideal solution for you. It must be placed at each sex act, and, if used correctly, the efficiency is 94%. It does not replace the use of condoms, it does not protect against sexually transmitted diseases.
Laura adds that between behavioral methods are found the rhythm method and withdrawal. The rhythm is nothing more than a calculation of the fertile period, in accordance with the menstrual period. Already in withdrawal, man must remove the penis into the vagina before he ejaculates.
It is a woman's right not want to get pregnant. For this, the ideal is to contact your gynecologist to choose the most appropriate contraceptive method for you. In the case of sterilization, it must be thought quite calmly and seriously, as there are high chances of the woman regret later.