Family Planning Post #10: Sterilization

This is the last of the posts set out to discuss particular methods of birth control. I will focus on the two main methods of elective sterilization--tubal ligation and vasectomy. After this post, I will move into a discussion of how we can put all this information together and think through it in a God-honoring fashion.

Quick note: Hysterectomy is another form of surgery that results in sterilization, but it does not tend to be something people choose right off--it is usually something that is deemed "medically necessary" for reasons other than birth control. I will briefly say that, because of the dramatic side effects associated with this operation, hysterectomy is something that a woman should try to avoid if at all possible.

Tubal Ligation

Tubal ligation or occlusion is a surgical procedure in which the fallopian tubes are cut, clamped, stitched, cauterized (burned), or blocked so that sperm are prevented from reaching the egg. The patient, the circumstances, and the physician's preference will determine the type of incision created. Some procedures are much more invasive than others. Please see the following links for more information on the variety of possibilities.

Web MD: Tubal Ligation and Tubal Implants
Baby Center: Tubal Ligation
About.com: Women's Health--Permanent Methods of Sterilization: Tubal Ligation Vs. Vasectomy

If you read these articles and/or do additional research, you'll see that tubal ligation is EXTREMELY popular worldwide and tends to be about 99% effective for the first few years. The failure rate increases over time, especially for women who have the operation at a younger age. Nevertheless, the operation should be considered PERMANENT. Reversals can be attempted but are most often unsuccessful.

There are a variety of side effects associated with tubal ligation, most of which are labeled "mild" by the majority of the medical community (see articles above for lists). However, there are some other "major" side effects which may be less common percentage-wise, so women tend to be ill-informed about them.

Post-Tubal Ligation Syndrome

Lumped under the title "post-tubal ligation syndrome" are long-term symptoms such as dysfunctional uterine bleeding (which is likely to result in hysterectomy), painful periods, excessive bloodflow during menstruation, increased mood swings and PMS, pain during intercourse, severe pelvic pain, and sudden premature menopause. (Info taken from Kippley and Kippley, The Art of Natural Family Planning, pp. 13-14 AND John Jefferson Davis, Evangelical Ethics, p. 38)

In reference to a study done on the menstrual problems women displayed after a tubal ligation, Davis goes on to write,

"The causes of these irregularities were not clear, but at least one investigator suggested that the sterilization procedure, by disturbing the normal blood circulation between the uterus and the ovaries, might have contributed to the menstrual disturbances suffered by the women," (p. 38).

Kippley and Kippley write in The Art of Natural Family Planning,

"If your friend or relative has recently had a tubal ligation and is telling you that everything is just fine, wish her good luck. There is good evidence that many of the women who will suffer from the post-tubal-ligation syndrome may not experience the bad effects until two years or more after being sterilized. 'At follow-up intervals longer than 2 years, the tubal sterilization group had significantly increased risks of abnormal menstrual cycles and combinations of two or more adverse menstrual outcomes.'45 The longer the follow-up on sterilized women, the higher the rates of problems. M.V. Muldoon reported that of 374 patients who were followed for at least 10 years after tubal ligation, 43% needed further gynecological treatments and 25% had major gynecological surgery [read hysterectomy].46" (p. 15)

The "funny" thing is that many women have their tubes tied after c-sections to avoid an increased risk of hysterectomy. However, it seems as though I've found quite a few sources who suggest that there is also an increased risk of hysterectomy with the tubal ligation.

Ectopic Pregnancy

The increased risk of hysterectomy and the long-term side effects of tubal ligation are bothersome to me, for sure, but right up there alongside them is the increased risk of ectopic pregnancy. While there is debate surrounding validity of claims that there is such a thing as post-tubal ligation syndrome (in that some people insist that there are no long-term side effects of tubal ligation), there is no debate about whether or not the rate of ectopic pregnancy increases with tubal ligation. Because the rate of tubal ligation failure increases over time, the risk of ectopic pregnancy goes up over time.

Kippley and Kippley describe well how this happens:

"A woman who has a tubal ligation and later becomes pregnant has a much higher chance of having an ectopic pregnancy than if she had not been sterilized. Why? The microscopic-sized sperm manage to get by the place where the fallopian tube was blocked, but the much larger conceptus cannot do so." (The Art of Natural Family Planning, pp. 14-15)

Why does this matter? We have established already that conception is the point at which human life begins and should be protected. Throughout my research, I have found this ectopic pregnancy issue to be most disturbing. When I carry it through to its logical conclusion, I cannot say that it is somehow different to create a situation where there is an increased risk--because of my CHOICE--that the human life would implant in the wrong place than it is to create a situation where there is an increased chance that it would not implant at all (as with the IUD or hormonal technologies).

The general consensus is that it is nearly impossible (some even say it is impossible) for a human life implanted in the wrong place to survive. Stewardship of my own body is a huge issue, so medical side effects that I will suffer are a problem. However, as I consider the possibility that I would be making a choice to decrease the chance that my baby would be able to survive, it makes it even more difficult for me to conclude that tubal ligation is a good way to go.

Just a few months ago, we had come to the less-than-settled conclusion that this would probably be the way that we would go when we find that enough is enough of the c-sections. While we had determined that this might be the best option based on a comparison of medical side effects associated with numerous c-sections vs. tubal ligation, I was still uneasy and not finished researching. Now that we have learned more, we have determined that this is not a good option.

So, what about...

Vasectomy

According to WebMD,

"During a vasectomy, the vas deferens from each testicle is clamped, cut, or otherwise sealed. This prevents sperm from mixing with the semen that is ejaculated from the penis. An egg cannot be fertilized when there are no sperm in the semen. The testicles continue to produce sperm, but the sperm are reabsorbed by the body. (This also happens to sperm that are not ejaculated after a while, regardless of whether you have had a vasectomy.) Because the tubes are blocked before the seminal vesicles and prostate, you still ejaculate about the same amount of fluid.It usually takes several months after a vasectomy for all remaining sperm to be ejaculated or reabsorbed. You must use another method of birth control until you have a semen sample tested and it shows a zero sperm count. Otherwise, you can still get your partner pregnant."

The operation should be considered PERMANENT. Reversals can be attempted but are most often unsuccessful.

John Jefferson Davis provides a helpful synopsis of vasectomy and related issues in Evangelical Ethics. Here are a few excerpts from his book:

"An increasingly common method of male contraception, vasectomy is undergone by some 750,000 American men each year.55 This represents a dramatic incrase since 1969, when 212,000 men underwent this sterilizing procedure.56

A vasectomy procedure, which can be done in a doctor's office or clinic, takes about 20 minutes and typically costs around $200.

... The vasectomy procedure involves the surgical excision of the vas deferens, the sperm-carrying duct. Due to the presence of residual sperm, a sterile condition does not result immediately. According to a study published in The Journal of the American Medical Association, vasectomy cannot be relied upon to provide 100 percent protection against pregnancy for at least six months after the operation. Researchers found that eight of 400 postvasectomy patients had transient reappearance of sperm in the semen from one to four months after the operation. All the patients studied became sterile seven weeks to six months after the operation.58" (p. 39)

Davis goes on to write,

"The general opinion in medical circles is that vasectomy is a safe and effective means of contraception with no significant harmful side effects. There have been a few physicians and medical researchers, however, who have raised questions about the effects of the prodedure. Dr. H.J. Roberts, who practices internal medicine in West Palm Beach, Florida, has expressed concern about evidence that men who have vasectomies can develop immune reactions to their own sperm. 'I know of no other operation performed on normal individuals that evokes immunologic responses of such magnitude,' Roberts observed.62

... This immune response to vasectomy is part of the body's effort to eliminate some of the 50,000 sperm that are produced each minute. According to Dr. John B. Henry, professor of pathology at the State University of New York Medical Center, the antibodies produced in reaction to the man's own sperm after vasectomy could prove to be 'an important compoenent in the evolution of autoimmune diesease,' though such a connection has not been definitely established.64 Some studies, but not all, have indicated a possible link between vasectomy and the risk of prostate cancer. While this possible link has not been firmly established, there is certainly cause for 'discussion ... and further research,' according to Dr. Stuart Howards at the American Urological Association.65" (pp. 40-41)

... and ...

"There are possible psychological as well as medical side effects to be considered in relation to vasectomy....

Men who have had problems with sexual dysfunction or histories of emotional instability before the operation are likely to find these conditions exacerbated afterward....71

While men with healthy egos and self-confidence can apparently accept the condition of sterility without psychological damage, that is not necessarily the case for men with marital or emotional problems. ...[S]ocial workers around the country report cases in which vasectomies have compounded sexual difficulties, increased anxieties and tensions, and helped to break up marriages." (pp. 41-42)

Here are a few more links that might help you learn more about possible side effects of vasectomy, which range from bleeding, swelling, continued fertility until the vas deferens is completely emptied, prolonged dull pain, immune reactions and even intense long-lasting pain.

WebMD: Vasectomy

National Institute of Child Health and Human Development (NICHD): Facts About Vasectomy Safety

NICHD: New Study Finds Vasectomy Does Not Increase Prostate Cancer Risk

VasectomyMedical.com: Post Vasectomy Pain Syndrome

Vasectomy.com: Vasectomy Risks and Complications

If It Works, Don't Fix It!--A Downloadable Book About the Risks of Vasectomy

National Cancer Institute: Vasectomy and Cancer Risk

There seem to be quite a few medical side effects that should DEFINITELY be considered seriously. You'll notice that there are varying opinions on the risk of various side effects (i.e. prostate cancer), but I think it's important that we at least read the information from both sides before making decisions.

Because vasectomy prevents sperm from being released from the male, it is seen as completely contraceptive in nature. Even if it fails, it has no opportunity to abort a human life.

Additionally, according to Vasectomy.com, "Tubal ligation is a more complicated sterilization procedure compared to vasectomy, which is safer, easier and just as effective." This statement is affirmed by everything else I've read.

BUT keep in mind that just because it's safer, easier, and just as effective as tubal ligation doesn't necessarily mean that it's totally safe, a total breeze, or without complications... or that it's necessarily biblically acceptable in any and every situation.

Biblical Considerations Regarding Sterilization

I could sit here and try to write out a helpful conclusion for you, but Andreas Kostenberger has done such a fabulous job in his book God, Marriage, and Family: Rebuilding the Biblical Foundation that I think I'm just going to quote him directly. It may be a long quote, but every sentence is key, so hang in there. The bold and underlined parts are my emphasis. Here goes...

"There are several important considerations with sterilization that may caution us against its use. For instance, it is an elective procedure that involves the intentional and permanent setting aside or inactivation of a bodily function. The permanence of the procedure makes it a different case from the use of a condom or other temporary measures. In addition, we might ask whether it is ever right to remove a part of one's body (cf. Lev. 21:20; Deut. 23:1; 1 Cor. 6:19) simply for convenience's sake,20 and whether this is the proper way to treat the body as the 'temple of the Holy Spirit' (1 Cor. 6:19).

In both Old and New Testaments, Scripture indicates that while care for the physical body is not to be of primary concern, it should be treated with honor and respect (cf., e.g., Gen. 2:7; Ex. 21:22-25; 1 Cor. 6:12-20). As ethicist John Jefferson Davis contends,

The apostle's point is that the believer does not have the right to exercise unlimited dominion over his or her body but should view the body as a trust from the Lord, to be cared for in ways that are glorifying to God. And surgical operation--such as sterilization--is not merely a personal "choice," but a decision that needs to be seen within the biblical framework of stewardship of the human body. Given the fact that our human bodies are a trust from God, and in light of the positive valuation placed on human procreative powers and large families in the Old Testament, these powers should not be rejected or surgically destroyed without compelling justification.21

While the subject has yet to receive adequate attention among evangelicals,22 some might respond that the same reasoning adduced above regarding the appropriateness of using certain forms of contraception applies here as well. God has given us intelligence and powers of judgment to fulfill his command to 'be fruitful and multiply' in our individual personal circumstances in keeping with scriptural commands and principles (such as the sacredness of human life). In light of our conclusion that it is fallacious to interpret this command to mean that every act of marital sexual intercourse must be open to procreation, it would seem appropriate that a given couple could determine that they have reached the point where they believe God would not have them conceive any more children. The question, then, becomes whether or not sterilization is a legitimate means of ensuring that no additional children are conceived. Indeed, while not every Christian would agree that sterilization involves an improper violation of one's body as the temple of the Holy Spirit,23 it is vital that believers submit their personal desires to a prayerful consideration of what is scripturally permissible.

While arguments can be made both against and in favor of sterilization as a form of birth control for Christians, therefore, since Scripture does not directly address the various forms of modern sterilization practices, it seems appropriate to refrain from dogmatism in this area. Where Scripture does not directly address a given matter, biblically informed principles must be applied to specific issues with wisdom and care. We have known godly couples who assured us that they pursued sterilization in an attitude of prayer and trusting the Lord. We have also known other, equally godly, couples who later regretted having followed through with this procedure and sought to reverse it in order to have more children. Both cases suggest that it is imperative that a couple who would use a given method honestly search their hearts and motives during the process of making such a decision and be certain that pragmatic considerations and personal desires do not override scriptural principles or unduly shape what they perceive to be the leading of the Holy Spirit.

... [W]ith regard to sterilization it is important to reiterate the need to take great care in avoiding dogmatism on matters that Scripture either does not prohibit or does not directly address. It is the principle of honoring 'the temple of the Holy Spirit' that one must seriously consider before deciding whether or not to employ such a method. ... [H]owever, it would seem that the consideration of scriptural principles ought to lead one away from employing sterilization... as a means of family planning." (pp. 136-8, 141-2)

Kostenberger's entire book is very helpful. If you're looking for further information on hormonal technologies, he provides several pages of information that might be helpful to you as well. The book is on sale at Amazon.com. If you invest in it, I'm sure it will be a blessing to many aspects of your own marriage and will be a great help to you as you walk through life with other married people (even if you're not married yourself). He spends several chapters laying a foundation for biblical marriage and family relationships. Based on this foundation, in addition to discussions of contraceptives, he also discusses fertility treatments, homosexuality, singleness, divorce and remarriage, qualifications for biblical leadership, etc. Check it out if you don't already own it!

So, then these questions remain... What is considered "compelling justification" for something as serious as permanent sterilization? And, if there is compelling justification, is it appropriate to choose either of the methods of sterilization available?

My plan is to write a post to summarize and discuss the possibilities for Christian couples seeking to employ some method of birth control.

In the meantime, what do you all think? What IS compelling justification for sterilization? If you see sterilization as a viable option for Christians, do you see a difference between tubal ligation and vasectomy?