Our Bodies, Ourselves (53 page)

If you become pregnant while using an IUD, have the IUD removed, whether or not you want to carry the pregnancy to term. An IUD in place increases the risk of miscarriage or premature birth. If the strings are not visible to remove the IUD, it is usually left in place until the end of the pregnancy, or removed at the time of an abortion.

Because the IUD is so effective at preventing pregnancy, women using IUDs are at lower risk of ectopic pregnancy (when a fertilized egg attaches and grows outside the uterus) than women using less effective contraception or no contraception at all. But in the unlikely event that a woman does become pregnant while using an IUD, she is more likely to have an ectopic pregnancy than other women. Ectopic pregnancy can be very dangerous and requires emergency medical attention. (For more information, see
“Ectopic Pregnancy.”
)

The IUD offers very effective protection from pregnancy without systemic side effects and decreases a woman's risk of getting endometrial cancer. The Mirena IUD decreases menstrual bleeding and cramping, and has recently been approved by the FDA for the treatment of heavy bleeding. Thirty percent of Mirena users stop having menstrual bleeding altogether. Mirena IUDs are also used in the treatment of endometriosis, although they have not been FDA approved for this use.

Longer, heavier, or more painful menstrual periods are the most common complaint of ParaGard IUD users. If you are already borderline anemic, increased menstrual flow may cause anemia. Some women have spotting between periods.

In the first three months of use, prolonged bleeding is also a common complaint with the Mirena. It takes about three months for the lining
of the uterus to thin down, and during this time, bleeding can be erratic or heavy at times; it almost always settles down after three to six months. During the first month, 20 percent of users experience bleeding of more than eight days in duration, but by the third month, only 3 percent have prolonged bleeding.

The side effects of the Mirena IUD are similar to those of other progestin-containing methods but are generally less intense, because the effects are more local and the blood levels of progestins are much lower. The Mirena can cause a slight increase in ovarian cysts. These cysts are benign and usually resolve in two to three months. Mirena rarely can cause headaches, acne, mood changes, and a decrease in sex drive.

If you want to become pregnant, you can have the IUD removed at any time. You may become pregnant immediately or within a few months.

The ParaGard IUD is very effective for emergency contraception. You can prevent pregnancy after unprotected intercourse by having a ParaGard copper IUD inserted within five days. It is 100 percent effective in preventing pregnancy and can then be left in place as a method of birth control for up to twelve years.
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There are several options for female sterilization: tubal ligation, Essure, and Adiana. They all work by stopping the egg from traveling to the uterus from the ovary and preventing sperm from reaching the fallopian tube to fertilize an egg.

Female sterilization should be considered permanent and irreversible. Although procedures exist to “untie” the tubes, they typically involve major surgery, cost many thousands of dollars, are not covered by insurance, and work only about half the time. In vitro fertilization, another option for sterilized women, is also costly and carries its own risks. You should consider sterilization only if you are certain you will not want to become pregnant in the future.

Tubal ligation, commonly known as “getting your tubes tied,” is a surgical sterilization technique that closes the fallopian tubes. In this procedure, fallopian tubes are cut, burned, or blocked with rings, bands, or clips. Tubal ligation is effective immediately. It does not protect against reproductive tract infections or sexually transmitted infections, including HIV.

A tubal ligation can be performed at any time under local or general anesthesia in a clinic, doctor's office, or hospital. Minilaparotomy and laparoscopy are the two most common techniques. Be sure to discuss the risks and benefits of different techniques with your health-care provider before deciding which one to use. If you are having a baby and want a tubal ligation afterward, talk to your doctor about sterilization options at the time of birth.

In a laparoscopy, the abdomen is filled with carbon dioxide gas so that the abdominal wall balloons away from the uterus and tubes. A laparoscope, a small telescopelike instrument, is inserted into a small cut just below the navel. Another instrument is inserted through an incision just above the pubic hairline to cut, sew, or burn the tubes. In a minilaparotomy, the surgeon makes a small incision just above the pubic hair and moves the fallopian tubes toward the incision to cut, sew, or burn the tubes.

After surgery, take two to three days off and
perform only light activities for a week. You may have sex again when you feel comfortable, usually after a week. If you have surgery performed through your vagina, don't put anything into your vagina for two weeks to avoid infection.

Essure is a method of sterilization that does not require surgery or general anesthesia. A small flexible spring is inserted into each fallopian tube. This sterilization technique is considered a major advance over surgical methods because it poses fewer risks of complications. Unlike surgical sterilization, Essure is not effective immediately; it becomes effective three months after the procedure, when an X-ray dye test shows that the tubes are successfully blocked.

The procedure is performed in a doctor's office. The doctor passes a thin, fiber-optic tube attached to a video camera through the cervical canal into the uterus, and inserts a tiny device into each fallopian tube. The devices expand, and over the course of about three months, fibrous tissue grows into them to block the tubes. In the United States, the FDA requires a test three months after Essure insertion to confirm that both fallopian tubes are blocked and the devices are in the right place. Rarely, the devices are found to be in the wrong location or have fallen out before the tubes are blocked.

Essure blocks both fallopian tubes 95 percent of the time. The most common reason for failure is that the doctor is unable to place the device in one or both fallopian tubes. Most women who have the procedure are able to go home about an hour afterward and return to work the next day.

Because Essure is made of the metal nickel, you should let your health care providers know you have been sterilized using the device. Some procedures—such as electrocautery of the lining of the uterus (endometrial ablation)—cannot be done with a metallic object present. Although research to date has shown the method to be very safe, its relative newness (it was introduced in 2002) means some risks may not have been identified yet.

Adiana is a new type of nonsurgical female sterilization that uses a silicon implant about the size of a grain of rice. Because it's nonsurgical like Essure, Adiana carries fewer risks than surgical sterilization. It becomes effective about three months after the insertion procedure, when an X-ray dye test shows that the tubes are successfully blocked.

The insertion is performed in a doctor's office. The doctor passes a thin tube through the cervical canal into the uterus. Radio waves released at the tip of the tube heat a short section of each fallopian tube. The tube is then used to place a tiny silicon implant on the heated spot. Over about three months, fibrous tissue grows into the implant to block the tubes. As with Essure, the FDA requires a test three months after Adiana insertion to confirm that both fallopian tubes are blocked. Research has shown that the method blocks both fallopian tubes 95 percent of the time.

All surgical sterilization procedures are over 99 percent effective. The nonsurgical procedures are 95 percent successful. Once properly placed, Adiana and Essure take three months to become effective. After the three-month follow-up test shows that the tubes are blocked, Adiana and Essure are more than 99 percent effective.

• Permanent birth control.

• Does not interrupt sexual spontaneity.

• Requires no daily attention.

• Cost-effective in the long run.

• Tubal ligation is immediately effective.

• Essure and Adiana are nonsurgical.

• Does not protect against STIs, including HIV.

• Tubal ligation requires surgery and has risks associated with surgery, such as bleeding, infection, and anesthesia problems.

• Essure and Adiana take three months to become effective.

• More risk than male sterilization.

• Should not be considered reversible.

• Possible regret, especially if done before age thirty or immediately after giving birth.

Tubal ligation is generally not recommended for women who have had difficulties with previous surgeries.

Adiana and Essure are not recommended for women with fibroids that change the shape of the uterus, women with iodine allergies (because the tests used to confirm blockage may contain iodine), or women who have given birth or had a pelvic infection in the last three months. Adiana is not recommended for women taking medications such as steroids that suppress the immune system. Essure is not recommended for women who are allergic or sensitive to nickel.

Tubal ligation is abdominal surgery and carries the risks of any surgery, including infection and a reaction to the anesthesia. If you have a high fever, swelling, or pus at the incision or severe abdominal pain or bleeding, call your doctor. You can shower the day after your surgery, but take care not to rub or pull on your incision for at least a week. Rest for a few days before you start all your normal activities again; you should feel fully recovered within a week.

If you had a laparoscopic procedure, your stomach may be swollen from the gas in your abdomen, and you may have back or shoulder pain. This will go away within a few days as your body absorbs the gas.

Following Essure or Adiana placement, serious complications occur in less than 1 percent of women. These can include an injury to the uterus, vasovagal response (slowing of the heart rate and dilation of the blood vessels, resulting in low blood pressure and light-headedness, which can occur during any gynecological procedure), or fluid overload (the absorption of too much water in the body, which can, in rare instances, lead to serious breathing problems or other complications). However, in studies, women with these complications recovered quickly and did not need to stay overnight in the hospital.

Pregnancy is unlikely after a successful sterilization (about one in two hundred women will become pregnant in the first year following sterilization). When a pregnancy does occur, it has a substantial chance of being located in the tube instead of in the uterus (ectopic pregnancy). This can be very dangerous and requires immediate medical attention. Women who have surgery to reverse a tubal ligation and become pregnant also have a higher chance of ectopic pregnancy. Thus, any pregnancy after sterilization (reversed or not) needs to be evaluated with ultrasound to ensure the pregnancy is within the uterus.

Female sterilization does not affect a woman's ability to enjoy sex. Usually, hormone levels and a woman's menstrual cycle are not noticeably changed by sterilization. Ovaries continue to release eggs, but the eggs stop in the tubes and are reabsorbed by the body. Some women experience improved sexual pleasure with the end of concerns about becoming pregnant.

Common side effects immediately following Essure and Adiana placement include mild uterine cramping or pain, nausea, and light bleeding. These usually go away within a few days.

After tubal ligation, some women report irregular and painful periods or no periods, midcycle bleeding, or lack of interest in sex. However, a large study of over ten thousand women found that those with surgical sterilization were more likely to have reduced bleeding and less menstrual pain compared with women who had not been sterilized, and no more likely to have midcycle bleeding.
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A third of the women in the study used a hormonal method of birth control, such as pills or Depo-Provera, before their sterilization procedure, and quitting a hormonal method can lead to cycle irregularity.

Female sterilization is considered a permanent method of birth control. Surgery to reverse a tubal ligation is effective only about half the time. Reversal procedures are technically challenging, expensive (over $5,000), and usually not covered by insurance. Another option for achieving a pregnancy after sterilization is in vitro fertilization.

A vasectomy is a sterilization technique for men. It involves minor surgery to cut the vas deferens, the tube that carries sperm from the testes to the penis. The man still produces semen, but when he ejaculates, there are no sperm in the semen.

Male sterilization is a simpler procedure than surgical female sterilization. It is usually done in a doctor's office or a clinic and takes less than fifteen minutes. The practitioner applies a local anesthetic (such as lidocaine), makes one or two small incisions in the scrotum, locates the two vasa deferentia, removes a piece of each, and ties or burns the end. Because sperm are already in the vasa deferentia, men are not sterile immediately. For this reason, it is important to use another method of birth control until the man has a negative sperm count, or for three months after the procedure. Since vasectomy does not protect against sexually transmitted infections, men should also continue to use condoms to protect against STIs.