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Sterilization is a surgical procedure performed to make a person incapable of reproducing. Another meaning (not treated here) refers to the killing of microorganisms. People in all parts of the world desire control of their fertility. Limiting the number of children allows each child more opportunity, and many women and families seek limits on their household size over their life course.
Limiting fertility is arguably also important for the environment. Population, exacerbated by affluence and consumption practices, especially in the developed world, has led to the appropriation of significant proportions of the biosphere, leaving diminishing habitat for other species. Under some calculations, humanity’s ecological footprint has now overextended 23 percent beyond the planet’s ability to sustain itself.
There are many techniques for both male and female sterilization. Male sterilization (vasectomy) interrupts the vas deferens, the tubes that transport sperm. It is usually performed with local anesthesia. Afterwards the man will be sore for a few days and should avoid strenuous work. There will still be sperm in his ejaculate for up to three months, so he should not rely on his sterility until a semen sample has been tested for sperm.
Because a woman’s fallopian tubes are inside her abdominal cavity, most female sterilizations involve one or two abdominal incisions. The fallopian tubes are interrupted by tying (hence the common name “tubal ligation”) or by coagulating with an electrical current. Clips or rings may also be used to block the tubes. Tubal ligation is effective immediately. General anesthesia is commonly employed, although the procedure can also be done with local anesthesia. A convenient time to perform female sterilization is shortly after the birth of a baby. Then the uterus is still large and a small incision through or near the umbilicus can be used to approach the tubes. With a cesarean delivery, the abdomen is already open, thus the tubes are readily accessible.
Female sterilization without incision is also possible. Essure® is already approved and available. It is a high-tech system that approaches the woman’s tubes through hysteroscopy-a technique to visualize the inside of the uterus. Quinacrine sterilization has been performed on about 100,000 women worldwide, but is not yet approved in the United States. It uses seven small pellets of quinacrine that are inserted without anesthesia through the woman’s cervix. Although this method is very inexpensive, its safety still needs to be proven.
Intrauterine devices (IUDs) offer a simple, reversible alternative to sterilization. Two are available in the United States: Mirena® is effective for five years, and Paragard® for at least 10. Both of these IUDs are comparable to sterilization in effectiveness. Other temporary methods of contraception are also available, but often with significantly less effectiveness than sterilization or IUD.
No contraceptive technique is completely effective. Sterilization failures can occur immediately, for instance if the man doesn’t wait for his vasectomy to become effective, or if the surgeon missed one of a woman’s tubes. Failures can also occur much later, if the vas or tube grows back together. Over a period of a decade the failure rate of tubal ligation may be as high as 2 percent.
Another shortcoming of sterilization is that it provides no defense against sexually transmitted diseases. Only condoms provide substantial protection against infectious agents, including HIV.
Some women will develop menstrual abnormalities as they get older. When a woman has had her tubes tied, then has heavy bleeding, she may blame the tubal ligation, but there is no evidence that tubal ligation leads to menstrual problems. Another concern has been about an increased risk of heart disease or prostate cancer in men who have had vasectomies, but studies have shown that there is no increased chance of these problems.
Sometimes people who have been sterilized will regret having had the procedure. This is sometimes due to divorce, other times due to the death of a partner or of a child. Furthermore, people change their ideas about their ideal family sizes. Regret is most common when people have sterilization done early in their reproductive lives. It is for this reason that no governmental agency will pay for a sterilization procedure if the person is under 21 years of age. The incidence of regret is twice as high if a woman has sterilization before age 30 than after.
There are two options for a woman who wishes to regain her fertility after tubal ligation. Tubal reanastomosis, or reconnecting the fallopian tubes, is effective about half the time. It is expensive and seldom covered by health insurance. In vitro fertilization bypasses the woman’s tubes and is effective after a tubal ligation. For the vasectomized man there is surgery to put the tubes back together.
Although vasectomy is safer and less expensive than female sterilization, in most parts of the world tubal ligation is more common than vasectomy. Worldwide there are about 180 million women who have been sterilized (including a relatively small number by hysterectomy). In contrast, only about 43 million men have had a vasectomy. In the United States the finding is similar; 41 percent of women,but only 26 percent of men, have been sterilized. In New Zealand, Holland, and Bhutan, more men than women have been sterilized, but this outcome remains unusual. There are fundamental questions about the equity surrounding the gendered distribution of responsibility for reproduction worldwide.
Sterilization programs operating at a large (national and international) scale have had a mixed and often unfortunate history. Pressure on poor communities and tribal members during India’s “emergency” of the 1970s, as a prominent but by no means unique example, led to involuntary and highly coercive sterilizations. Where women control their choices and their bodies, however, sterilization has helped millions of couples prevent unplanned pregnancies, and it remains the single most popular birth control choice in the world.
- Global Footprint Network, www.footprintnetwork.org;
- Betsy Hartmann, Reproductive Rights and Wrongs: The Global Politics of Population Control (South End Press, 1995);
- A. Hatcher, et al., Contraceptive Technology, 18th ed. (Ardent Media, 2004).