Contraception - Permanent methods: Nursing

Permanent methods of contraception are surgical procedures that permanently prevent future pregnancies. So, for individuals assigned females at birth, tubal ligation surgery is done to achieve permanent contraception, while in the case of individuals assigned males at birth, vasectomy is performed. Of note, even though they are widely accepted as “irreversible” methods, in some situations, these procedures can be reversed.

Now, to understand the tubal ligation and vasectomy, let’s start by having a look at the anatomy and physiology of the fallopian tubes in assigned females and the vas deferens in assigned males at birth.

The fallopian tubes, also known as oviducts or uterine tubes, are a pair of tube or pipe-like structures on each side of the uterus that connect it with the ovaries. This way, during the menstrual cycle, it helps in transporting the ova or oocyte from the ovary to the uterus. Each fallopian tube has four sections: the uterine section, which opens into the uterus; the isthmus, which is the tightest part of the tube; the ampulla, which is the widest part of the fallopian tube where fertilization usually occurs; and the infundibulum, which envelops the ovary with finger-like projections called fimbriae.

Switching gears, let’s look at the anatomy of the vas deferens, which refers to a pair of thick long tubes that carry mature sperm from the epididymis to the ejaculatory ducts. The ductus deferens begins at the inferior pole of the testis, then ascends posterior to the testis to enter the spermatic cord, which connects the testes to the abdominal cavity. From there, the ductus deferens enters the pelvic cavity and goes over the bladder, and then descends medial to the seminal vesicle.

The ductus deferens then terminates by joining the ducts of the seminal vesicle, forming the ejaculatory ducts which connect to the urethra. During transport from the vas deferens to the urethra, the sperm collects secretions from the male accessory sex glands such as the seminal vesicles, prostate gland, and bulbourethral glands, which provide the bulk of semen. During ejaculation, the semen leaves through the urethra.

So, in individuals assigned female at birth, the operative procedure to achieve permanent contraception is bilateral tubal ligation. It involves the use of clips, banding or cautery to clamp down the fallopian tubes, or the tubes can be removed altogether. Most often, tubal ligation is done in a postpartum setting, either during a cesarean delivery, or 1 or 2 days after vaginal delivery. Alternatively, it can be performed at a time unrelated to childbirth.

Another technique of tubal ligation involves a non-surgical approach, where a nickel coil is inserted into the fallopian tubes. Over time, as tissues grow in and around the coil, it slowly occludes the tubes, achieving mechanical blockage of fallopian tubes, which can then be removed or occluded with electrocoagulation. The risk of pregnancy is extremely low following bilateral tubal ligation, however, in case it does happen, it comes with a high risk of ectopic pregnancy.

Similarly, in individuals assigned male at birth, a vasectomy can be performed to achieve permanent contraception, by blocking the sperm made by the testes from reaching the semen. The procedure involves interruption or occlusion of each ductus deferens and is typically performed in an outpatient setting under local anesthesia.

Now, there are two methods for vasectomy. Conventional vasectomy is a traditional vasectomy approach which involves bilateral scrotal incisions through which each ductus deferens is mobilized and transected. Another method is no-scalpel vasectomy, which is associated with almost little to no bleeding, less chances of infection, and pain. A puncture is made through the scrotal skin overlying the vas deferens and widened only enough to externalize the vas deferens for transection.