Is tubal ligation truly permanent. How does Medicaid affect access to tubal ligation. What are the challenges women face when seeking tubal ligation through Medicaid. Why are there differences between private insurance and Medicaid for tubal ligation access. How has COVID-19 impacted tubal ligation procedures.

Understanding Tubal Ligation: A Permanent Birth Control Option

Tubal ligation, commonly known as “having your tubes tied,” is a permanent form of birth control for women who have decided they do not want to have more children. This surgical procedure involves cutting, tying, or blocking the fallopian tubes to prevent eggs from reaching the uterus and being fertilized.

As the second most common method of contraception in the United States, tubal ligation is particularly popular among Black and Hispanic women, as well as those with public health insurance or no insurance at all. Many women opt to have this procedure done immediately after giving birth, taking advantage of their hospital stay to undergo the surgery.

Is tubal ligation truly permanent?

While tubal ligation is considered a permanent form of birth control, it’s important to note that in rare cases, it can be reversed. However, the reversal procedure is complex, expensive, and not always successful. Therefore, women considering tubal ligation should be certain about their decision not to have more children in the future.

Medicaid and Tubal Ligation: Navigating the Bureaucratic Maze

For women whose healthcare is covered by Medicaid, obtaining a tubal ligation can be a challenging process due to bureaucratic hurdles. These obstacles often stem from well-intentioned but outdated policies that now paradoxically restrict women’s reproductive autonomy.

What are the specific Medicaid requirements for tubal ligation?

Women covered by Medicaid who wish to undergo tubal ligation must complete the “Consent to Sterilization” section of Medicaid’s Title XIX form. This form must be signed at least 30 days, but no more than 180 days, before the procedure. Even in emergency situations, a 72-hour waiting period is required.

These requirements can create significant barriers for women seeking tubal ligation, especially when combined with other factors such as:

• Lack of access to prenatal records at the time of delivery
• Inability to resign consent forms if the initial 180-day period has elapsed
• Restrictions on using telehealth for obtaining consent during the COVID-19 pandemic

The Impact of Medicaid Policies on Women’s Reproductive Choices

The current Medicaid policies surrounding tubal ligation have far-reaching consequences for women’s reproductive health and autonomy. These policies, which were initially implemented to protect women from forced sterilization, now often have the opposite effect.

How do Medicaid policies affect access to tubal ligation?

The stringent requirements and bureaucratic hurdles associated with Medicaid coverage for tubal ligation result in only about 53% of desired procedures actually being performed. This leaves many women without their preferred method of contraception, potentially leading to unintended pregnancies and additional physical and emotional stress.

Moreover, women covered by Medicaid are particularly vulnerable to unintended pregnancies and often have limited access to care. Many lose their insurance coverage soon after giving birth, making it even more crucial for them to have access to reliable, long-term contraception.

Private Insurance vs. Medicaid: A Tale of Two Standards

The disparities between private insurance and Medicaid coverage for tubal ligation highlight a concerning inequality in access to reproductive healthcare.

How does private insurance coverage for tubal ligation differ from Medicaid?

Patients with private insurance can typically obtain a tubal ligation whenever they choose, without the need for prerequisite paperwork or waiting periods. This creates a two-tiered system where those with private insurance have ready access to permanent contraception, while those on public insurance face significant barriers.

Interestingly, this disparity is also reflected in vasectomy rates. While vasectomies covered by Medicaid face similar limitations to tubal ligations, only five states explicitly cover permanent male contraception in their state-regulated health plans. Vasectomy rates tend to increase with higher education and socioeconomic status, making them more common among men with private insurance.

The COVID-19 Pandemic: Amplifying Existing Barriers

The ongoing COVID-19 pandemic has further complicated access to tubal ligation for women covered by Medicaid, exacerbating existing barriers and creating new challenges.

How has the pandemic affected tubal ligation procedures?

The pandemic has drastically changed medical practices, particularly in obstetrics and gynecology. Many outpatient visits, including prenatal and routine gynecological appointments, have been converted to telemedicine to minimize patients’ exposure to high-risk hospital and clinic settings.

However, Medicaid has maintained its requirement for in-person signatures on consent forms, even during the pandemic. This stands in contrast to many hospitals that have updated their procedures to allow verbal consent in order to minimize contact.

The Case for Change: Reforming Medicaid Policies on Tubal Ligation

Given the numerous challenges and inequalities surrounding Medicaid coverage for tubal ligation, there is a growing call for policy reform.

What changes could improve access to tubal ligation for Medicaid patients?

Several potential reforms could help address the current issues:

1. Eliminating or reducing the mandatory waiting period
2. Allowing for electronic or verbal consent, especially during public health emergencies
3. Extending the validity period of consent forms beyond 180 days
4. Improving communication between prenatal care providers and hospitals to ensure access to signed consent forms
5. Aligning Medicaid policies with those of private insurance to create a more equitable system

The Broader Implications: Reproductive Autonomy and Healthcare Equity

The issues surrounding Medicaid coverage for tubal ligation reflect broader concerns about reproductive autonomy and healthcare equity in the United States.

How do current policies affect women’s reproductive rights?

While the original intent of Medicaid’s tubal ligation policies was to protect women from coerced sterilization, they now often have the opposite effect. By creating significant barriers to a desired form of contraception, these policies can be seen as infringing on women’s reproductive autonomy.

Furthermore, the disparities between Medicaid and private insurance coverage highlight ongoing inequalities in the healthcare system. These differences disproportionately affect women of color and those with lower socioeconomic status, who are more likely to rely on Medicaid for their healthcare needs.

Looking Forward: Advocating for Change in Tubal Ligation Policies

As awareness grows about the challenges surrounding Medicaid coverage for tubal ligation, there is an increasing push for policy reform and advocacy efforts.

What steps can be taken to address these issues?

Addressing the current challenges will likely require a multi-faceted approach:

• Raising awareness among policymakers about the unintended consequences of current Medicaid policies
• Advocating for policy changes at both the federal and state levels
• Encouraging healthcare providers to speak out about the barriers they encounter when trying to provide tubal ligation to Medicaid patients
• Supporting research to better understand the impact of current policies on women’s health outcomes and reproductive choices
• Promoting educational initiatives to ensure women are fully informed about their contraceptive options, including tubal ligation

By addressing these issues, we can work towards a more equitable healthcare system that respects women’s reproductive autonomy and ensures equal access to contraceptive options, regardless of insurance status.

The Role of Healthcare Providers in Navigating Tubal Ligation Challenges

Healthcare providers play a crucial role in helping women navigate the complex landscape of tubal ligation, particularly for those covered by Medicaid.

How can healthcare providers better support women seeking tubal ligation?

There are several ways in which healthcare providers can assist their patients:

1. Providing comprehensive counseling about all contraceptive options, including the permanence of tubal ligation
2. Ensuring patients understand the Medicaid requirements and timelines for tubal ligation
3. Assisting with the timely completion and submission of necessary paperwork
4. Advocating for patients when bureaucratic hurdles arise
5. Offering alternative contraceptive options when tubal ligation is not immediately available
6. Staying informed about policy changes and updates related to Medicaid coverage for tubal ligation

By taking these steps, healthcare providers can help mitigate some of the challenges posed by current Medicaid policies and ensure their patients receive the care they need and desire.

The Intersection of Tubal Ligation and Reproductive Justice

The issues surrounding Medicaid coverage for tubal ligation intersect with broader concepts of reproductive justice, which emphasize the right to have children, not have children, and parent children in safe and healthy environments.

How do tubal ligation policies relate to reproductive justice?

The current Medicaid policies on tubal ligation raise several concerns related to reproductive justice:

• They disproportionately affect women of color and those with lower incomes, who are more likely to rely on Medicaid
• They limit women’s ability to make autonomous decisions about their reproductive futures
• They potentially contribute to unintended pregnancies, which can have significant impacts on women’s health, economic status, and overall well-being
• They highlight ongoing inequities in the healthcare system based on race, class, and insurance status

Addressing these issues through policy reform and increased access to tubal ligation for Medicaid patients would be a significant step towards greater reproductive justice and healthcare equity.

The Economic Impact of Barriers to Tubal Ligation

The challenges surrounding Medicaid coverage for tubal ligation have economic implications for both individual women and the healthcare system as a whole.

What are the economic consequences of limited access to tubal ligation?

The economic impacts of current policies include:

1. Increased costs associated with unintended pregnancies, including prenatal care, childbirth, and potentially abortion services
2. Lost productivity for women who experience unintended pregnancies
3. Increased strain on social services and support systems
4. Potential long-term economic consequences for women and families dealing with unplanned additions to their families
5. Inefficiencies in the healthcare system due to bureaucratic hurdles and missed opportunities for timely procedures

By improving access to tubal ligation for Medicaid patients, we could potentially reduce these economic burdens and create a more efficient and equitable healthcare system.

Comparing International Approaches to Tubal Ligation Access

Examining how other countries approach access to tubal ligation can provide valuable insights and potential models for improving the situation in the United States.

How do other countries handle access to tubal ligation?

Policies and practices regarding tubal ligation vary widely around the world:

• In many European countries, tubal ligation is readily available and often covered by national health insurance systems without extensive waiting periods or paperwork
• Some countries, like Brazil, have faced criticism for overly aggressive promotion of tubal ligation, particularly among low-income women
• In contrast, countries like Japan have historically had more restrictive policies, requiring spousal consent for tubal ligation
• Many developing countries are working to increase access to a range of contraceptive options, including tubal ligation, as part of broader family planning initiatives

By studying these different approaches, policymakers in the United States could potentially identify best practices and avoid pitfalls when considering reforms to Medicaid policies on tubal ligation.

The Future of Contraception: Beyond Tubal Ligation

While addressing the challenges surrounding Medicaid coverage for tubal ligation is crucial, it’s also important to consider the broader landscape of contraceptive options and emerging technologies.

What new contraceptive options might impact the demand for tubal ligation?

Several advancements in contraceptive technology could influence the future of permanent birth control:

1. Improved long-acting reversible contraceptives (LARCs) that provide highly effective birth control for extended periods
2. Non-surgical sterilization methods that may be easier to access and perform
3. Advancements in male contraception, potentially shifting some of the contraceptive burden away from women
4. Personalized contraception based on genetic and hormonal profiles
5. Novel delivery methods for hormonal contraceptives, such as microchip implants or self-administering injections

As these technologies develop, they may provide alternatives to tubal ligation or influence how permanent contraception is approached. However, it remains crucial to ensure equitable access to all contraceptive options, regardless of insurance status or socioeconomic background.

Empowering Women: Education and Informed Decision-Making

Regardless of the specific policies or technologies available, empowering women to make informed decisions about their reproductive health is paramount.

How can we improve education and decision-making around tubal ligation?

Several strategies could help improve the situation:

• Comprehensive sex education in schools that includes information about all contraceptive options, including permanent methods
• Improved counseling and education in healthcare settings about the pros and cons of tubal ligation
• Development of decision-making tools to help women weigh their options and consider long-term implications
• Increased public awareness campaigns about reproductive health and contraceptive choices
• Support for peer education and community-based programs that provide culturally sensitive information about family planning

By focusing on education and informed decision-making, we can ensure that women have the knowledge and support they need to make the best choices for their reproductive health, whether that includes tubal ligation or other contraceptive options.

Medicaid needs to change its rules for women seeking tubal ligation

First Opinion

By Divya Dethier, Megan L. Evans and Erin Tracy BradleySept. 16, 2020

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For many women who don’t want to have more children, childbirth offers a safe and convenient time for adopting the permanent form of birth control known formally as tubal ligation, and informally as having your tubes tied. For women whose health care is covered by Medicaid, senseless bureaucracy can make this difficult.

A patient we will call Sofia (we aren’t using her real name to protect her privacy) is a perfect example of this issue. She had wanted to have a tubal ligation after she delivered her fourth child in March. The timing was bad: It was the peak of Covid-19 in Massachusetts, where Sofia was having her baby, and staffing and resource limitations meant she was unable to get the procedure as planned. She left the hospital with a plan to reschedule her procedure for later.

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Once elective surgeries began to start up again in June, Sofia was scheduled to rebook her tubal ligation and go over pre-op instructions. But because it had been more than six months since she had signed the paperwork that Medicaid requires from all women seeking this procedure, she needed to have an in-person visit before she could be booked for her surgery — a telehealth visit wasn’t allowed since she had to physically sign the paperwork again. When Sofia came in to sign the paperwork, the pregnancy test she had at the visit (which is routinely done before this type of surgery) was positive.

Tubal ligation, the second most common method of birth control in the United States, is used more by Black and Hispanic women and women with public or no health insurance. Many women desiring this procedure have it done immediately after giving birth, while they have ready access to care.

If a woman covered by Medicaid wants her tubes tied, she must complete the “Consent to Sterilization” section of Medicaid’s Title XIX form at least 30 days, and no more than 180 days, before having the procedure. An emergency waiver still requires a 72-hour waiting period, though in obstetrics, emergencies rarely last 72 hours.

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All too often, a patient covered by Medicaid who receives prenatal care at a community health center delivers her baby at a hospital lacking access to her prenatal records, including the signed consent form — and by that time it is too late to resign. If any of the requirements are not met, Medicaid will not pay for the procedure.

As a result of these barriers, only about 53% of desired tubal ligations are actually performed.

This policy began in 1978 as a way to protect publicly insured women from forced sterilization, at a time when federally insured women were often victims of reproductive coercion. Although initially well-intentioned, many experts agree that this policy now paradoxically discriminates against publicly insured women by imposing additional burdens to getting the permanent contraception they desire and restricting their reproductive autonomy.

As a result, many Medicaid patients leave the hospital with no contraception and at higher risk of unintended pregnancies, not to mention the additional physical and emotional toll that comes with pregnancy and delivery. Women covered by Medicaid are particularly at risk for unintended pregnancy and have limited access to care, as they can lose their insurance coverage soon after delivering a baby.

Although vasectomies covered by Medicaid also include these limitations, only five states explicitly cover permanent male contraception in their state regulated health plans. Contrary to tubal ligation, vasectomy rates tend to increase with more education and higher socioeconomic status and so are more common among men covered by private insurance.

Privately insured patients, female and male, can get a tubal ligation or vasectomy whenever they choose, without any prerequisite paperwork or 30-day waiting period. This creates two standards of care whereby those with private insurance have ready access to permanent contraception while those on public insurance are not afforded the same timely access.

The Covid-19 pandemic has amplified these barriers as the disease radically changes the way medicine is practiced. In obstetrics and gynecology, many outpatient visits, including prenatal visits and routine gynecology visits, have been converted to telemedicine to minimize patients’ unnecessary exposure to high-risk hospital and clinic settings. Many hospitals during the pandemic, including the ones we work in, have updated their standard procedures for obtaining consents, recommending verbal consent to sign on behalf of a patient to minimize contact.

Medicaid, however, has made it clear that even during Covid-19, patients must still sign the Medicaid-specific consent form in person for the procedure to be covered. This means adding an unnecessary, burdensome office visit that takes time away from work for the patient as well as increases the risk of exposure to SARS-CoV-2, the virus that causes Covid-19, for her and her baby.

Patients like Sofia, who had signed the consent form before Covid-19 and had their procedures delayed have now fallen outside the 180-day waiting period and must come in for an office visit to sign it again, and then wait another 30 days to schedule a procedure they have already been counseled about and expressed a desire to have done.

We live and work in Massachusetts, a state that values reproductive justice and maternal health. With nearly half of pregnancies being unintended, one important step to reducing maternal mortality is by giving women the choice and the agency to make decisions about their fertility – and allowing patients who wish to prevent pregnancy to do so.

There were ample missed opportunities for preventing Sofia’s unplanned pregnancy. The waiting period for tubal ligation mandated by Medicaid was an unnecessary and archaic barrier before Covid-19, and even more challenging and pertinent now.

The pandemic will undoubtedly bring more unanticipated and unplanned barriers to accessing and receiving health care. In other parts of the health care system, it has spawned flexibility, resourcefulness, and rapid adaptation. It should trigger the same response in Medicaid. We urge policymakers to take advantage of this forward momentum: allow electronic signatures, expand telemedicine capabilities for consent, extend the 180-day expiration and, in doing so, give publicly insured women the reproductive autonomy they need and deserve.

Divya Dethier is in her final year of residency in obstetrics and gynecology at Brigham and Women’s Hospital and Massachusetts General Hospital in Boston. Megan L. Evans is an obstetrician and gynecologist at Tufts Medical Center and assistant professor of obstetrics and gynecology at Tufts University School of Medicine in Boston. Erin Tracy Bradley is an obstetrician and gynecologist at Massachusetts General Hospital and associate professor of obstetrics, gynecology, and reproductive biology at Harvard Medical School.

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Tubal ligation – how effective is female sterilisation surgery

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Key facts

• Tubal ligation is a permanent form of contraception for females.
• It is usually done using keyhole surgery.
• Normally you don’t need to stay in hospital overnight.
• Only consider tubal ligation if you are sure you don’t want to have a baby.

What is a tubal ligation?

Tubal ligation is a procedure to block or cut the fallopian tubes. It is a permanent form of female contraception.

Tubal ligation is very effective at preventing pregnancy. Less than 1 in every 100 females who has a tubal ligation will get pregnant.

Another name for this procedure is laparoscopic sterilisation.

What does a tubal ligation involve?

If you have a tubal ligation, your fallopian tubes will be clipped, cut and tied, or sealed shut.

This stops your eggs from moving from your ovaries to your uterus. It stops sperm from meeting and fertilising an egg.

What are the benefits and risks of tubal ligation surgery?

Benefits

The main benefit of tubal ligation is that neither you nor your partner need to use another method of contraception. It’s a permanent way to prevent pregnancy.

Tubal ligation does not change your hormones or your menstrual cycle (periods).

Risks

It is difficult to reverse tubal ligation.

Having your tubes tied does not protect you from sexually transmitted infections.

While tubal ligation is very good at preventing pregnancy, it is not 100% effective. There is also a small risk of ectopic pregnancy after having a tubal ligation. An ectopic pregnancy is a pregnancy outside your uterus. It can cause dangerous internal bleeding and needs immediate treatment.

What does the operation involve?

You will need to have a general anaesthetic to put you to sleep. The operation is usually done using keyhole surgery known as laparoscopy.

Your doctor will make one or 2 small cuts in your lower abdomen (tummy). A small camera called a laparoscope is used so that the doctor can see your fallopian tubes. Your tubes are then sealed with rings, ties, clips, or heat. Sometimes they are cut and tied.

Sometimes the procedure needs to be done in a different way. This is called a laparotomy, and involves a larger cut in your abdomen (tummy). After a laparotomy, you may need to stay in hospital for a few days to recover.

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How soon will I recover?

If you have laparoscopic (keyhole) surgery, you should be able to go home on the same day that you have your operation.

It takes a few days to recover. The general anaesthetic may make you feel nauseous or tired. You might have abdominal (tummy) pain after the operation.

You’ll need to rest for at least 1 to 2 days after the operation. You may feel more tired than usual for a few weeks. Take pain relief, such as paracetamol, if you need to.

After a week or so, it is usually safe to resume regular activities. Gentle exercise can help you recover. You will need to avoid heavy lifting for a while longer. Check with your doctor first.

What are the possible complications of tubal ligation?

Possible side effects and complications include:

• tummy or shoulder pain
• bleeding
• infection

Discuss any risks with your doctor before your operation.

What if I change my mind later? Can tubal ligation be reversed?

It is sometimes possible to have another operation to repair your fallopian tubes after tubal ligation. Only about 1 in 2 females get pregnant after a reversal.

You should only have a tubal ligation if you are sure that you don’t ever want to become pregnant in the future. Make sure you feel certain that you won’t want any more children, even if things change in your life, such as a new relationship.

If you are thinking about a tubal ligation, talk about the risks and benefits with your partner and your doctor. You may also want counselling to talk this decision over.

What are the alternatives to tubal ligation?

There are many alternative methods of contraception. Some of these include:

• permanent male sterilisation — vasectomy
• an intrauterine device (IUD)
• contraceptive implants
• birth control pills
• male contraception using a condom

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Resources and support

The Health Translations website has information on contraception choices, including female sterilisation. This is available in a few languages and in simple text.

• Health Translations — Contraception choices
• Health Translations — About contraception (video)

You can also call the healthdirect helpline on 1800 022 222 (known as NURSE-ON-CALL in Victoria). A registered nurse is available to speak with 24 hours a day, 7 days a week.

Sources:

Sexual Health Victoria
(Tubal Ligation (Sterilisation)),
Family planning NSW
(Permanent Contraception: Female Sterilisation),
Therapeutic Guidelines
(Overview of tubal sterilisation)

Learn more here about the development and quality assurance of healthdirect content.

Last reviewed: November 2022

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• Laparoscopic sterilisation

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Ovarian and fallopian tube cancer

Treatment of epithelial ovarian/fallopian tube cancer

Early treatment of high-grade ovarian/fallopian tube cancer often involves surgery and adjuvant chemotherapy. Treatment for more advanced HGSC consists of surgery with adjuvant chemotherapy and/or targeted therapy, neoadjuvant chemotherapy followed by surgery, or chemotherapy alone if surgery is not an option.

Treatment of ovarian germ cell tumors

The first treatment given for ovarian germ cell tumors is usually surgery. In some cases, doctors can perform surgery while preserving fertility. Depending on the stage and subtype of germ cell cancer, doctors may recommend adjuvant chemotherapy after surgery.

Treatment of stromal tumors

Stromal tumors are a type of ovarian cancer. They are found in the connective tissues that hold the ovaries together. For stage I stromal cancer, treatment usually consists of surgery alone. For high-risk tumors in the early stages and in stage III or IV disease, doctors often consider combination chemotherapy. It can be used after surgery or in the treatment of tumors that reappear after treatment, that is, recurrent tumors. If the disease recurs, hormonal therapy may be prescribed. Research is underway to find other targeted drugs for the treatment of ovarian stromal tumors.

Treatment of metastatic cancer

If the tumor spreads to another part of the body, outside the organ in which it originated, it is called metastatic cancer.

New treatments for metastatic cancer include an experimental combination of chemotherapy, targeted therapy and immunotherapy. The goal of this treatment is to strengthen the body’s natural defenses against cancer. Palliative care is essential to reduce symptoms and side effects.

Remission and the possibility of recurrence

Remission is a condition in which cancer cannot be detected in the body and its symptoms are also absent. Remission can be temporary or permanent. If the oncoprocess returns after primary treatment, it is called recurrent. Distinguish between local (in the same place), regional (near) or distant recurrence.

When a relapse occurs, a new series of tests should be done to find out as much as possible about it.

Treatment of recurrent cancer

Chemotherapy is the most commonly used. The main goal of treating a relapsing disease is to reduce or prevent symptoms of the disease while minimizing side effects. Treatment of women with relapse of the disease depends on the time elapsed since the last treatment. It is based on taking platinum chemotherapy drugs (carboplatin and cisplatin). If the cancer returns more than 6 months after such therapy, it is platinum sensitive. If the cancer returns less than six months after treatment, doctors call it platinum-resistant.

Surgery is usually only considered if 1 year or more has passed since chemotherapy. If the cancer recurs in more than one site, chemotherapy is an appropriate next step.

Medicines are selected from a list of medicines that have demonstrated a similar ability to reduce cancer. Doctors choose them based on possible side effects and preferences depending on the dosing regimen. Bevacizumab can be combined with liposomal doxorubicin, paclitaxel, or topotecan for the treatment of platinum-resistant cancer.

Symptoms of recurrence

Signs of relapse are similar to those in the initial diagnosis of the disease. The most common are urinary symptoms (urgency or frequency), early satiety, and dyspepsia. However, persistent indigestion, gas, nausea, diarrhea, or constipation may be added to these symptoms; unexplained weight loss or gain, especially in the abdomen abnormal bleeding from the vagina; pain during intercourse; fatigue and pain in the lower back.

If treatment fails

If the disease cannot be cured or controlled, it is called progressive or terminal.

The medical team has the special skills, experience and knowledge to support patients and their families, always ready to help. It is extremely important to provide a person with physical comfort, freedom from pain and emotional support.

Sterilization in Moscow, making an appointment with a doctor for a fee and free of charge online, get a doctor’s consultation in clinics, hospitals, medical departments and medical diagnostic centers – Clinics of Moscow

Sterilization is a medical procedure performed to impair the ability to conceive a child (artificial infertility) used as contraception.

Male and female sterilization is performed surgically. For this, surgical intervention is performed (ligation of the vas deferens or vasectomy in men, tubal ligation in women), aimed at achieving a permanent (irreversible) inability to conceive. Ligation of the vas deferens leads to the absence of spermatozoa in the ejaculate. Tubal ligation makes fertilization physically impossible (due to impaired tubal patency and the impossibility of fertilizing the egg).

Male sterilization is performed under local or general anesthesia. The procedure for tubal ligation in women is performed under general anesthesia and requires abdominal surgery. For this reason, sterilization in women is rarely performed as an independent intervention, carried out in the presence of medical indications, and not at the request of the woman. Sterilization in women is often combined with a caesarean section. The most minimally invasive type of sterilization is laparoscopic clipping of the fallopian tubes with titanium clips.