The Barriers to Getting Your Tubes Tied

Tubal ligation is the most common form of birth control in the United States, but as I found out the hard way, not every physician wants to perform the surgery.

I discussed the procedure with my doctor while waiting to go into the operating room for a cyst removal. My doctor was hesitant because he thought I would change my mind later in life, which is absurd considering the facts: I'm 32, have multiple children already and have experienced adverse health effects from various birth control options.

The one factor that finally changed his mind was my husband sitting next to my hospital bed providing his "consent."

I consider myself lucky that the timing of the conversation provided the right circumstances to persuade my physician to perform the procedure, and I was able to overcome the barriers of my insurance company. However, many women are forced to leave their physicians and go elsewhere to receive permanent birth control options.

Why doctors don't want to perform them

According to the Centers for Disease Control and Prevention (CDC), tubal ligations are the most common form of birth control, with most sterilizations performed immediately following childbirth. However, for women who don't want children or do not fit the predetermined parameters for tubal ligation, getting this procedure done can be nearly impossible.

"Historically, I believe the driving factor in physicians' opposition to sterilization for young (under 40) and childless women has been cultural rather than financial," said Rebecca Kluchin, Ph.D., associate professor of history at California State University, Sacramento and author of "Fit to Be Tied: Sterilization and Reproductive Rights in America, 1950–1980."

"They believe that women are meant to be mothers, that most women, if given the choice, will choose to have children and those who request sterilization, especially if they are young and/or childless, haven't really thought their decision through," Kluchin continued.

The issue of doctors' hesitation regarding tubal ligation has become so prevalent that the American College of Obstetricians and Gynecologists (ACOG) addresses paternalism as a concern in its guidelines for evaluating patients for elective sterilization. According to the ACOG Practice Bulletin, Interim Update from 2013, "Patients should not be denied sterilization because of the presence of such risk factors, especially young age. The choice to undergo sterilization is an individual and personal decision. It is critical that healthcare providers refrain from inserting their own biases or judgments about the appropriateness of a patient's decision to proceed with sterilization."

Sterilization is your choice

An added barrier to sterilization is that many religious and private healthcare institutions also have the right to determine what care they will provide, and are protected under a U.S. Supreme Court decision that allows healthcare professionals to turn away patients seeking tubal ligation services under the protection of religious freedom.

This leaves many women unable to get a tubal ligation, which is something Planned Parenthood Keystone CEO Melissa Reed is all too familiar with. "When people who seek permanent sterilization are turned down, it really goes back to this paternalist viewpoint people have about an individual's ability to make their own personal or sexual decisions," she said.

Who can get a tubal ligation?

In theory, any woman who doesn't want to have children should be able to have a tubal ligation. However, if you're under 21 or have never had children, you may find there is some added bureaucracy to carry out this choice. Regardless of age, it's important that patients understand the risks of the procedure and realize that while reversal procedures exist, these procedures may not be possible if you have your fallopian tubes removed (bilateral salpingectomy) during the procedure. Even if the reversal is successful, your chances of getting pregnant are substantially reduced.

In truth, only 14 percent of patients request reversal information, and of this number, only 1 percent actually have the reversal performed, according to ACOG. Regardless of these statistics, most physicians will recommend semi-permanent procedures, such as an intrauterine device (IUD), subdermal implant or even a vasectomy, as these procedures carry lower risks than tubal ligation.

ACOG recommends that physicians counsel patients about the process of sterilization as well as the risks and the permanence of the procedure to ensure that patients understand the choice. Unfortunately, even after this conversation, many physicians still hesitate to perform a tubal ligation because they are concerned that patients will regret it later in life.

'It is critical that healthcare providers refrain from inserting their own biases or judgments about the appropriateness of a patient's decision to proceed with sterilization.'

"Because [the women] are still fertile, there's a chance they could change their minds, so doctors believe that temporary contraception is a better option," Kluchin added. "The problem with this reasoning, of course, is that it undercuts women's right to make choices about their own bodies."

For women seeking sterilization, doctors' concerns are not the only barrier to overcome. Once a patient can persuade their physician to perform the surgery, there are often insurance challenges to deal with, too. Most insurance companies require consent from the patient, which may need to be signed as far as 30 days in advance, unless the procedure is performed alongside another procedure, such as a cesarean section or, in my case, a laparoscopy.

Understanding why a doctor would deny the procedure is important in preparing for your appointment. If you have a partner, you may want them to come with you. If you are single and do not have children, check with your insurance company first to ensure you are within the criteria for coverage. Do your research and show your physician that you have fully weighed the risks. The more knowledge you have, the better the conversation will go. Most importantly, don't be afraid to seek the help of nonprofit organizations to find a provider who will perform this procedure safely and with your well-being at the forefront of care.