Introduction
Family planning can be seen as a program to regulate the number and spacing of children in a family through the practice of contraception or other methods of birth control (American Heritage Dictionary, 2009).Contraception is a major component of preventive health care for women. Several methods are used for family planning, but tubal ligation is different from other contraceptive because often it isn’t reversible.
Recently, due to decreased in acceptability of tubal ligation in women, there are questions on safety of this method. Families with numerous children (5 or more) are common phenomenon in our environment Researchers has found that appropriately half of the children were the result of unplanned pregnancies.
When human reproduction is left unchecked, it results into high birth rate, bringing about large family, community and a nation with the negative effect on the health especially of the mother and children.
Overpopulation is a global problem affecting both developed and developing countries. Nigeria is by far the most populated in Africa with a total population of 140 million in 2006 census and on annual population growth, rate of 3.0%. Nigeria maternal mortality and total fertility rates rank among the highest in the world (Ogonna, 2012).
Tubal ligation, commonly known as “getting your tubes tied” is a surgical sterilization techniques for women. This procedure closes the fallopian tubes and stops the egg from travelling to the uterus from the ovary. It also prevents sperm from reaching the fallopian tubes to fertilize an egg (Trussel & James, 2011)
According to Lukeman (2012) the increasing trend toward smaller families in developed countries coupled with the availability of new technology and simpler, safer and more effective surgical techniques during the 1970s has led to increased demand for voluntary sterilization.
Female sterilization is the most commonly used “modern” contraceptive in the Unites States. About 27% of women who have chosen to use contraceptive have chosen to use tubal sterilization (National Survey of Family Growth (2006).
Sterilization is one of the most effective means of preventing unwanted pregnancy. Almost 50% of all pregnancies each year are unintended, and majority occur among women who are using one contraceptive or the other (Collins 2014)
Bilateral tubal ligation is the most commonest method of contraception worldwide but is yet to gain wide acceptance in Nigeria as a result of ignorance illiteracy, superstitious belief an some myths surrounding it. In this region, women believe that procreation will be impossible after a tubal ligation (Igberase, 2006).
Conceptual framework
Every year hundreds thousands of women are faced with the challenges of choosing a family planning method. That is driven by fear of unknown consequences from the use of hormonal contraceptive, fears of unplanned pregnancies resulting from less effectiveness and sometimes fears of exercising sexual self control.
Female sterilization is most frequently accomplished through a small sub umbilical incision or by mini laparoscopy techniques and are crushed, ligated, electro coagulated, banded or plugged (in the newer reversible procedure).
Tubal ligation may be done at any time. However, the postpartum period, the most ideal period to perform a tubal ligation because the tubes are somehow enlarged and are easily located. The need for thorough counseling during decision making cannot be over emphasized. Actual information concerning the procedure should be given for the acceptor not to experience regret in years or times to come. Reproductive health care (2006) suggests waiting 6 weeks after the woman has given birth before carrying out the procedure. Reproductive health care also suggest that if sterilization is going to be carried out at the same time as an elective section, then 1 week or more should be given for counseling and decision making before the procedure takes place.
Overview of the female reproductive system
The female reproductive system (or female genital system) contains two main parts: the internal female reproductive organs comprises the vagina, uterus, uterine tubes (fallopian tubes, oviducts) and ovaries and the external female reproductive which include the mons pubis, pudendal cleft, labia majora, labia minora, bartholins glands and clitoris.
- The vagina: The vagina is a fibro muscular tubular tract leading from the uterus to the external of the body in female mammals. The vagina is where semen from the male penis is deposited into the female’s body at the climax of sexual intercourse, a phenomenon known as ejaculation. The vagina is a canal that joins the cervix to the outside of the body (Robert, 2014).
- Cervix: The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is a cylindrical or conical in shape. The vagina has a tick layer outside and it is the opening where the fetus emerges during delivery.
- Uterus: The uterus or womb is the major female reproductive organ of humans. The uterus is a pear shaped muscular organ. Its major function is to accept a fertilized ovum which becomes implanted into the endometrium and derives nourishment from blood vessels develop exclusively for this purpose. The fertilized ovum becomes an embryo (weeks 1 to 8), develops into a fetus (from week 9 until the delivery) and gestates until childbirth. If the egg does not embedded in the wall of the uterus, a female begins menstruations (Wikipedia, 2014).
- Fallopian tube: The fallopian tubes or oviducts about 10 cm long are two tubes leading from the ovaries into the uterus (Saladin 2010). Fertilization usually occurs here (Oviducts), but can happen on the uterus itself. On maturity of an ovum, the follicle and the ovary wall rupture, allowing the ovum to expand and enter the fallopian tube, there it travels towards the uterus, pushed along by movements of cilia on the inner lining of the tubes. This trip takes hours or days. If the ovum is fertilized while in the fallopian tube, then it normally implants in the endometrium when it reaches the uterus, which signals the beginning of pregnancy (Freedmen & David, 2010).
- Ovaries: The ovaries are small paired organs that are located near the lateral walls on the pelvic cavity. These organs are responsible for the production of ova and the secretion of hormones.
Contraception
According to (Merrian, 2015) contraception are things that are done deliberately t o prevent a woman from becoming pregnant. Dawn (2015) defined contraception as the use of different devices, sexual practices, techniques, chemicals, drugs and /or surgical procedures to purposely try to prevent pregnancy.
Types of contraception
Not all contraceptive methods are appropriate for all situations and the most appropriate method of birth control depends on a woman’s overall health, age frequency of sexual activity, number of sexual partners, desires to have children in the future and family history of certain diseases. The different method of contraception include: Barrie methods, Hormonal methods, emergency contraception, intrauterine methods and sterilization.
- Barrier methods: This method is designed to prevent sperm from entering the uterus. Barrie methods care removable and may be an option for women who cannot use hormonal methods of contraception. Types of barrier methods include: male condoms, female condoms, diaphragms which include cervical caps, contraceptive sponges and spermicidal.
- Hormonal methods: Hormonal methods of birth control use hormones to regulate or stop ovulation and prevent pregnancy. Hormones can be introduced into the body through various methods; pills, injections, skin patches transdermal gels, vaginal ring, intrauterine system and implantable rods.
- Intrauterine Methods: An IUD is a small T-shaped device that is inserted into the uterus to prevent pregnancy. It includes a copper IUD and a hormonal IUD.
- Tubal Ligation: Is a surgical procedure in which a doctor-cuts, ties or seals the fallopian tube.
- Vasectomy: Is a surgical procedure that cuts, closes or blocks the vas deferens.
Concept of tubal sterilization
Prior to the 1960s, female sterilization in the United States was generally performed only for medical indications (when additional pregnancies would be hazardous to the mother). The changing cultural climate in the 1960s encouraged women to reduce family size. During the same decade, surgical advances resulted in safe, less invasive female sterilization procedure when childbearing was no longer desired. Currently, approximately 700,000 bilateral tubal sterilization are performed annually in the United State, of these, half are performed postpartum and half are ambulatory interval procedures. Eleven million US women aged 15-44 years rely on internal tubal occlusion for contraception and more than 190 million couples worldwide use surgical sterilization as a safe and reliable method of permanent contraception (Robert K. 2015).
Surgical procedures
Surgical approaches for female sterilization include laparoscopy, hysteroscopy, micro laparoscopy, laparotomy, minilaparotomy and vaginal approaches.
- Laparoscopy: Is a surgical sterilization procedure in which a woman’s fallopian tubes are either clamped or blocked or severed and sealed (Jessica, 2015).
- Hysteroscopy: Is a type of a tubal sterilization procedure that uses the body’s natural openings to place a small implants into the fallopian tube. No surgical incision is needed (FAQ180, 2013).
- Laparotomy: Laparotomy is defined as abdominal entry through an incision greater than 5cm and is performed under general or regional anaesthesia. It is associated with more complication.
- Minilaparatomy: According to (Robbert, 2012) minilaparotomy is defined as a laparotomy with incision size smaller than 5cm. The operation can be performed through a supra pubic incision in the interval after pregnancy and through a sub-umbilical incision within the first 48 hours after delivery.
- Transvaginal approaches: Culdoscopy (direct visual examination by the female visera through an endoscope introduced into the pelvic cavity through the posterior vaginal fornix (Barbara, Weller, 2006) and colpotomy (incision into the wall of the vagina (Tanya, 2014).
The vaginal approaches was once preferred but since it is associated with higher risk of infections, it is no longer recommended.
Mechanical device
Devices and application specific to mechanical method include:
– Tubal clip
– Tubal ring
– Ensure tubal ligator
– Adiana tubal ligator
Timing of female sterilization
Female sterilization can be performed at any time before or after pregnancy ( Alison, 2013), It include:
- Postpartum: Postpartum tubal sterilization can be performed at the time of care delivery or shortly after a vaginal delivery. It is indicated for any patient who is medically stable after delivery.
- Post abortion: Post abortion sterilization can be performed immediately after a uncomplicated spontaneous induced abortion with increased risk compared with an internal procedure.
- Interval: Tubal occlusion can be performed as an interval procedure separate from pregnancy.
Mechanism of action of tubal ligation
Tubal ligation works by closing the fallopian tube which stop the egg from travelling to the uterus from the ovaries and prevent sperm from reaching the fallopian tube to fertilize an egg (Justice and McNall. 2009).
Effectiveness of tubal ligation
Tubal ligation is approximately 99% affective in the first year following the procedure. In the following year the effectiveness may be reduced slightly since the fallopian tube can be some cases reform or reconnected which can cause unintended pregnancy. Failure rate less than (0.0-0.8%) this figure does not include women who conceive at the time of sterilization. Overall failure rate 0.2-4% for first year, fewer failure generally occurs in subsequent year.
Side effects of tubal ligation
- Abnormal bleeding
- Pain
- Changes in sexual behavior
- Increased pre- menstrual distress
- Risk of ectopic pregnancy
- Uterine relapse
- Uterine peroration
Tubal ligation failure
It is possible to become pregnant following tubal ligation. The failure rate is low at 2-10/per 1,000 women. There is no 100% guarantee for any form of tubal ligation, should you become pregnant; you will usually have a normal pregnancy.
However, you move a higher chance of ectopic pregnancy (the society of obstetricians’ and Gynecologist of Canada).Reason for failure include : occlusion of an incorrect structure, slippage of a mechanical device spontaneous re–anastomosis of the cut ends.
Counseling issues in tubal ligation
Female sterilization is the number zone contraceptive choice among women in united states. Counseling issues include ensuring that the women understands the permanence of the procedure and knowing the factors that correlate with fituru regret. Factors that correclate with future regret (PUB FACTS. 2016). According to Basavantapa (2007) as cited by Samuel (2011) is defined as a state of knowing about a particular fact a situation. Therefore, for a woman to appreciate the important of bilateral tubal ligation must base knowledge about the method of family planning.
Tubal ligation reversal
A tubal ligation reversal is a procedure to restore fertility after a woman has a tubal ligation. During a tubal ligation reversal, the blocked segments of the fallopian tube are reconnected to the remainder of the fallopian tubes. This may allow eggs to again move through the tubes to join an egg. Sterilization procedure that cause the least amount of damage to the fallopian tubes are the most likely to allow successful tubal ligation reversal. Examples, sterilization with tubal clips or rings (Richard 2015)
Conceiving after tubal ligation
Women who have tubal ligations structure regret their decision and desire fertility in the future. There are two (2) options for fertility after tubal ligation: tubal reversal surgery and invitro fertility ligation (IVF). Tubal ligation reversal usually requires a laboratory ( incision on the abdomen). There are 5 important issues regarding tubal reversal surgery that need to be considered and discussed; the sperm quality of the male partner, tubal status, status of other possible pelvic conditions female age and egg quality and quantity (Advanced fertility centered of Chicago, 2015).
Advantage of tubal ligation
- It is a permanent form of birth control
- Immediately effective
- Does interfere with sexual intercourse
- Highly effective method of contraceptive (99%)
- After the procedure is complete, it is private form of birth control
- Does not affect menstrual circle or libido
- Cost effective in the long run.
- No significant long term side effect
- Requires no daily attention
Disadvantage of tubal ligation
- Required minor operation to be performed
- Slight chance of failure
- Reversal is expensive
- Does not protect against sexually transmitted disease
- Possible post sterilization regret
- If pregnancy does occur there is a higher choice that it will be an ectopic pregnancy
Complications
- Bleeding, infection or reaction to an aesthetic may occur
- Damage to organs, including the bowel, bladder, uterus, ovaries, blood vessels and nerves may also occur ( 1 to 4% of cases)
- Although rare, deaths.
Tubal ligation regret and risk factors
A study carried at public teaching hospital Brazil in 1997 showed that, women showing a significance regret were those sterilized at young age, those for whom the sterilization was carried out up to the 45th day afterbirth and those who had acquired knowledge about contraceptive method after the tubal ligation procedure. It is therefore necessary to assess women’s psycho , socio- demographic profiles, their reasons for requesting tubal ligation (Cadermos, 2009).
Factors influencing women’s choice on bilateral tubal ligation
According to Kinuthia (2013) these factors may be grouped into four which include economic factor, socio- demographic, cultural and religion belief.
- Socio–economic: Factors such as poverty greatly affect the choice of whether or not a women will take up bilateral tubal ligation. A poor couple with low educational level will more after have a higher number of children compare to educated and well to do couple.
- Socio–cultural factor: This has greatly affected the acceptance of family planning. Communication and agreement between husband and wife in respect to family planning is very important. A couple that has open communication about their family planning option will reach an amicable agreement on their choice, but a situation where the husband instructed his wife not to undergo any method , of course the uptake of method such as BTL will be hindered.
- Socio- demographic: this is another factor affecting choice of family planning. In developing countries – United States, there is increasing choice of bilateral tubal ligation acceptance compare to developing countries – Nigeria as a result of poor facilities and unskilled personnel.
- Religion: Religion belief has negatively impacted on the choice of family planning. The Roman Catholic do not believe in the use of contraception, as such their members do not.
These factors will all be booked into in this study in order to elucidate, how they impact on a woman’s decision to take up bilateral tubal ligation.
References
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Richard, M.S (2015). Tubal reversal surgery or invitro fertilization after tubal ligation. Retrieved February 28, 2016. Chicago: Advance Fertility Center of Chicago. www.advanced.cedfertility.com./tubalr eversal.wim.
Samuel, P. & Ludernir, A.B. (2013). Risk factors for tubal sterilization regret detectable before surgery. Retrieved march 19, 2016. Permakube: cad.Saude publica. www.scielo. br/roojcube/ep dfphp/doi =101590 s0102-311 x 200900060o18&pid = s010s-311 x 2009000600 & pdf-path=csp/v25n6/18.
Soheiha, E., Maedeh, M.& Nafise, S. (2010). Iran J Nurs midwifery Res.Retrieved February 9, 2016 from Msc thesis Isfahan University of Medical Sciences.
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