A Stitch in Time

Sterilization is a safe and easy method of birth control. The hardest part is deciding to do it.

June 1979By Comments

A few months past my thirty-fifth birthday, on a warm day in August, I took a Friday afternoon off from work and had my tubes tied.

As abrupt as that may sound, the decision was, in fact, anything but sudden. I suppose I had been moving gradually toward it all of my adult life. The ironic thing was that I had always assumed I would someday have children. My first husband and I even decided that four would be a good number. We discussed whether they should be planned close together or far apart and we made up funny names for sets of twins. But the years went by and a “good” time to start a family just never came along.

Neither set of parents pressured us to have children. The only person who was really in favor of the idea was my doctor. (“When are you going to get pregnant? You young girls sure have an easier time of it.”) I felt a little envious when my high school and college chums started having children, but the combined problems of work, graduate school, and money made us keep postponing the decision. These same problems ultimately took their toll on the marriage, which ended, as do many first marriages these days, in divorce.

By the time I married again, in my early thirties, my life had changed substantially. Instead of a low-paying job I now had a well-paying career, the feminist movement had given respectability to women who choose not to have children, and I found myself in a role I had never expected: stepmother to my husband Tim’s three youngsters. Although they didn’t live with us all the time, they were a boisterous handful during their extended visits. Tim said that, frankly, they were all the children he could handle.

I had things that many women only dream of: a wonderful marriage, work that I really liked, nice kids who didn’t take up all my time, a comfortable house that just suited our needs and pocketbook. To me, it seemed absurd to tamper with such a perfect combination.

Besides, I was 35, and realistically or not, that age had always seemed the cutoff for childbearing. It was the age of increasing birth defects and difficult labor for first-time mothers. It was also the age at which women on the pill (as I was) could expect an ever-greater risk of heart attacks, strokes, and blood clots. And then there was the problematic relation of cancer to the hormone estrogen, the primary component of birth control pills. “There is no proof,” my gynecologist said emphatically, “that birth control pills cause cancer.” And he was right. There was no proof. But there were disturbing studies suggesting a possible link between uterine cancer and estrogen therapy in menopausal women, and that, combined with everything else, was enough to give me second thoughts about staying on the pill.

No one thing really made up my mind. I just knew that I didn’t want a baby and I didn’t want to take the pill. I hardly realized how much I had been silently dwelling on the subject until I saw how much I startled poor Tim when I announced one evening, without prelude, “I’m going off the pill and I think one or the other of us should get sterilized.”

We had talked before—in the abstract—about switching to another birth control method, but the alternative contraceptives seemed at worst unhealthy and unreliable, at best messy and unreliable. After each of those discussions I had resigned myself to the pill again; now that the easy alternative seemed less desirable, we found ourselves face to face with the toughest question yet: Who?

And that is the crux of the issue—no one wants to be sterilized. No one wakes up one morning and says to himself, “Say, I think I’ll get a vasectomy today.” Sterilization of either sex is not without risk, and that is why for six weeks Tim and I made an effort to weigh the pros and cons. We went to my doctor’s office and saw a film on tubal laparoscopy (the most common method of female sterilization—actual tying is seldom done anymore, even though the expression persists). I talked to some friends who had had the operation. We read what was published in news magazines. It seemed to us that tubal laparoscopy carried greater physical dangers, from complications during and after surgery, but vasectomy had the risk of psychologically caused impotence and related personal problems. In addition, less is known about the long-term physical complications of vasectomy.

We didn’t exactly overeducate ourselves, though, maybe because we subconsciously felt that if we knew too much, both of us might back out. We didn’t do much talking, either, other than a few cryptic sentences, usually around midnight. “Well, what do you think about it, honey?” “I don’t know, sweetheart, what do you think?” Each of us, of course, was waiting for the other to volunteer, or perhaps for a sign that the other was never going to volunteer. That signal became clear to me the day I realized Tim had said to me three times, “My only objection to vasectomy is…”—and all three reasons had been different.

My own concerns, though real, were obviously not as troubling. I knew the operation was low risk, that it wouldn’t affect my sex life or femininity, and that side effects were usually minimal. The only thing that continued to bother me was the question of regret. Would I later be sorry I had never had a child of my own? Society is very definite in its insistence that motherhood is a blessing (no one expects you to explain why you want a baby, but everyone turns into an armchair psychologist as soon as you mention that you don’t want one). Besides, I firmly believe that every human being has a strong inner drive to reproduce, and this desire isn’t easily bought off by such things as rationality and common sense.

Even though it seemed that my health and happiness would be best served by not having a child, I continued to mull over my decision, right down to the minute I arrived at the modern new medical center where the operation was to be performed.

At 11:30 Friday morning I checked in, a little nervous and hungry (I hadn’t been allowed to eat since midnight—normal preoperative procedure), but otherwise in good spirits. A clipboard with my insurance papers and a plastic nametag for my wrist were waiting at the desk. The entire bill—including surgery, anesthesia, room, and lab tests—came to $750, of which my insurance policy paid all but a few dollars. While the attendant checked that I had signed the form saying I understood the operation would leave me sterile, I idly calculated that, at $4 per month, birth control pills for twenty years (the rest of my reproductive life) would have cost me $960.

In the patients’ area a nurse issued me a pair of blue-green drawstring pants, a short flowered gown, and a pair of foam-soled slippers and told me to change. Since an hour or so remained before my operation and I couldn’t concentrate on the book I had brought to read, I spent the intervening time pacing restlessly down the hall and around the nurses’ station, occasionally stealing a quick look into a room to see how the other patients, mostly women there for the same reason I was, were faring. I remembered reading in a report released by the National Center for Health Statistics that in 1976 an amazing 28 per cent of American women of childbearing age were voluntarily sterile, almost all of them for reasons of contraception.

At three o’clock the nurse in charge said, “They ought to be ready for you in about twenty minutes. Your doctor is doing six of you girls this afternoon, and you’re number six.”

In less than half an hour another nurse appeared at the door to my room and walked me down long halls and through an endless number of swinging double doors to the operating room.

A two-time veteran of surgery, I was prepared for the stainless-steel efficiency of the operating room, the forceps and syringes, the huge lights, and that awful chill, but it was still awe-inspiring. I tried to remain inconspicuous on a low stool to one side while nurses unfolded sterile sheets and laid out surgical instruments.

A nurse helped me onto the operating table while the anesthesiologist, a dapper, gray-haired man, surveyed my medical history and, as he had no doubt done with hundreds of nervous patients, made small talk to calm my anxiety.

Quietly starting the anesthesia, he said, “Now in just a few seconds you’ll start to feel a little drunk. Feel it now?”

I did. The last thing I remember is the doctor saying pleasantly, “Off to sleep you go.”

Although I didn’t, of course, see my own operation, one month later I watched my doctor perform the same procedure on another patient. To my surprise I found the whole thing much too fascinating to make me nervous or even queasy.

Once the patient is anesthetized, a nurse straps her into the stirrups, then meticulously lathers the abdomen and pubic area with a no-nonsense ocher-colored disinfectant. She shaves a patch about the size of a nickel from the upper edge of pubic hair, where the second of the two incisions will be made. Two other nurses unfold sterile blue disposable sheets and operating gowns and lay out rubber gloves and the various parts of the laparoscope—the instrument that has, in the last decade, revolutionized female sterilization. This technique is the most popular method presently in use in the country.

The word laparoscopy is a compound of laparo, Greek for “flank,” and scope, “a viewing device.” Basically, it involves the insertion into the abdomen of two tubes, one for viewing and the other for surgical instruments (in some laparoscopes, these tubes are combined). Because only one or two tiny incisions are required, laparoscopy greatly reduces physical trauma and allows the patient to go home the same day she has the surgery. Interestingly, the technique was pioneered for fertility research by Dr. Patrick Steptoe, who was recently involved in the creation of the first test-tube baby.

When everything is ready, the surgeon dilates the patient’s cervix, using a series of dilators about the diameter of a pencil (first, of course, removing her IUD if she has one). A small curved tube, or cannula, is then inserted through the vagina into the uterus; this tube will be used to manipulate the uterus from side to side during the surgery so the physician can obtain a clear view of any organs that the uterus might normally obscure.

The first incision, just one-fourth inch long, is made slightly under the navel. The few trickles of blood are quickly wiped away. Through this small opening the doctor inserts a hollow, double-walled needle, known as a Verres needle, which is connected to a large tank of carbon dioxide beside the operating table. Turning on the flow, he gently inflates the abdominal cavity like a balloon. The approximately three liters of carbon dioxide raise the abdominal wall three or four inches above the internal organs, allowing an unobstructed view into almost the entire lower portion of the torso.

With a machine monitoring the flow of CO2, the physician widens the incision a bit. Then, with a well-controlled thrust, he inserts the laparoscope through the tight, narrow opening into the cavity. Attaching a telescope and a fiber-optic bundle (which produces a cool light that will not burn body tissues), he scans the internal organs, occasionally removing the eyepiece and dipping one end in a heated saline solution so that it won’t fog up—like a cold windshield—in the warmth of the patient’s body. After making the second incision in the shaved patch just inside the pubic hair line, he inserts a tube to accommodate the surgical instruments.

Illuminated by the bright light of the optical fibers, the interior of the human body is strangely beautiful. More than anything else, it resembles an undersea garden: anemones, corals, and exotic ocean creatures. The intestines are smooth and pink, the liver a rich burgundy brown. Fat reclines in liquescent gold globules. Hugging each white ovary is a pink fallopian tube, which snakes off to join the coral-red uterus some two inches away.

After scanning the abdominal cavity, the physician inserts a pair of long, specially designed forceps through the lower tube. While looking down the scope, he grasps the first fallopian tube about an inch from where it joins the uterus. Pressing a foot switch, he turns on an electrical current, which passes through the forceps and in an instant neatly cauterizes and seals the tube. With each pulse of electricity, a barely audible “zap” is heard. The current is on for no more than three seconds altogether. The doctor then snips the center of the cauterized area (some physicians don’t cut at all; others seal two areas and remove a section of the tube) to be double sure that neither sperm nor egg can pass. When the first tube is finished, the second is treated in exactly the same manner.

An alternative method of sealing off the tubes is to place a small plastic band, called a Silastic ring, around the tube to squeeze it permanently shut. Although it is only slightly less effective than cauterization as a means of contraception, it has advantages that some patients and physicians feel outweigh its drawbacks. The biggest advantage is that unlike the electrocautery method, it carries no risk of accidentally burning the lower intestine, thus necessitating a regular operation to repair the damage. Its biggest drawback seems to be that in a few cases it causes some persistent abdominal and lower-back discomfort.

In both methods there is a risk, again very small, of hemorrhage or that internal organs or blood vessels may be perforated by the laparoscope, the inflation needle, or the cannula that is inserted into the uterus. Despite all of this, the operation is extremely safe. Each year 600,000 women undergo tubal sterilization in the United States. In 1976, the most recent year for which figures are available, major complications occurred at a rate of fewer than three per thousand. The death rate that year was four per hundred thousand; in 1975 it was zero.

Once a woman has been sterilized by tubal laparoscopy, the chances of her becoming pregnant are negligible; the operation is 99.94 per cent effective. Although rare, a few pregnancies, both tubal and normal, have occurred, apparently when an egg or a sperm managed to migrate through a small break in the seal and, miraculously, leap the gap between the two ends of the tube. (Incidentally, more tubal pregnancies occur with the Silastic ring). Such cases make headlines and lawsuits, but in the vast majority of cases sterilization is permanent and complete.

When the tubes are sealed, the operation is all but over. The laparoscope is removed from the abdomen and the carbon dioxide is allowed to escape through the incisions. The surgeon swiftly closes them with four small stitches each, Band-Aids are applied, and the nurses lift the patient onto a stretcher for the short trip to the recovery room. The time elapsed from beginning to end of surgery is less than fifteen minutes.

Back in my room, after groggily coming to in the recovery area, I found that while I didn’t exactly feel good, I didn’t feel bad either. The sharp pain of the fresh incisions quickly subsided, and I felt nauseated from the anesthesia only if I moved too quickly. It was good to hear the nurse say, “Everything went fine; she did great,” better yet to have Tim, who was waiting for me, hold my hand. Regaining consciousness was a gradual process, and I napped off and on while odd, disconnected thoughts drifted through my mind. Vaguely, I recalled the half-dozen female cats I had marched off to the vet to be spayed, to have them return home on wobbly legs, with a small shaved patch on one furry side. Strange how my empathy for them had suddenly increased.

In two hours I was alert enough for a slow walk around the hall, and four hours after returning from surgery I dressed, descended to the parking lot in a wheelchair, and went thankfully home, relieved that it was over and that everything had gone so smoothly.

The first three days after the operation were so uneventful as to be boring. A friend brought over a book and some flowers Sunday afternoon and was amazed to see how fit I looked; that evening Tim and I went out to eat. Basking in my new role as star patient, I was secretly astonished at my own recuperative prowess. The only discomfort I had was an ache in my shoulders and neck that, as the doctor told me, was actually pain from my still somewhat bloated abdomen, mentally “displaced” to another part of my body. It’s a common occurrence with this operation, and one Percodan tablet relieved it completely. But I noticed that the pills—or something—had started making me wakeful at night.

A couple of hours of lost sleep I could cope with, but eight hours of tossing and turning all Monday night made my mood change abruptly from cheerful to glum, and before I even got out of bed, I knew that something was definitely not going right.

The mind is so much at the mercy of things outside itself—sleep, drugs, the body’s own hormones, the weather—that it’s a full-time job staying on an even keel under normal conditions. Under abnormal ones, such as after an operation, one’s emotional equilibrium is decidedly off balance.

I hadn’t expected to be depressed. I certainly didn’t want to be depressed. But to my unpleasant surprise I found myself submerged in the blues, dredging out of my subconscious every scrap of regret I had earlier set aside.

For two days or more I hardly left the house. In fact, I hardly left the bedroom. I shifted from bed to chair to bed again, berating myself for my certainty about the operation. We could have had a child. We could have added a room on to the house. I could have exercised and gotten myself in shape. I could have had amniocentesis to be sure the fetus was normal. I could have quit my job for three or four years. It was all feasible. Why hadn’t I thought of the advantages of having a baby as thoroughly as I had cataloged the disadvantages?

Coaxed out of the house for lunch at a neighborhood restaurant, I spoiled everyone’s meal by snuffling and sniffling for 45 minutes over a perfectly innocuous remark Tim made. He was baffled. He couldn’t understand why, when everything had been going so well, it was now going so badly. And to be honest, neither could I.

On the third day of the siege, even though my mood hadn’t improved, I began to seriously distrust my emotions. Why was I doing this to myself? I had spent weeks thinking this through ahead of time. Everything I was crying over now I had carefully weighed before. Finally, on the fourth day of the depression, a flash of insight came—while I was brushing my teeth. Unlike great moments of self-knowledge in literature, my revelation was neither succinct nor poetic, but its very awkwardness was, to me at least, proof of its sincerity. In a sentence, the depression was the price that I felt society was exacting from me for making a rational decision about an emotional subject. Or, to look at it from another angle, I hadn’t been sorry enough that it wasn’t my lot in life to have children. And why this ritual regret? Why now rather than before? Simple. If I had put myself through all of this before the operation, I might not have gone through with it.

The mental relief this convoluted reasoning gave was immense and immediate. I slept that night. I went to work the next day. Best of all, I began to take an interest in things outside myself.

Looking back at it now from the distance of several months, I think my bout with depression was caused as much, if not more, by physiological stress as by my psyche. Any surgical procedure can cause emotional swings, and one that involves a woman’s reproductive cycle, which is notoriously subject to ups and downs, is a double-jeopardy situation. Now that considerable time has elapsed, all the scars have faded. The two tiny incision lines are all but invisible; I could wear a bikini, if I were so inclined, and no one would even notice them. My physiology is perfectly normal. My menstrual periods are as they were in my preoperative, pre-pill days, and my sex life is just fine. The only discomfort I still have is an occasional sensitivity in the lower abdomen, around the cauterized areas of the tubes, that comes on during my period or after sitting in a cramped position for a while. It has never bothered me enough to warrant even an aspirin, though, and it always goes away in a couple of days. I’ve heard of other women who say they can “feel” their tubes, but it doesn’t seem to be a universal result by any means.

As for my mental outlook, it couldn’t be better. Sterilization proved to be a watershed in my life: of other decisions I have made, only two—marriage and divorce—have affected me as profoundly. But now that time has passed and the results of what I did have meshed with the cycle of days and weeks and months that make up life, I am more certain than ever that the decision I made was right.

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