Editor’s note: This article was corrected to reflect that Essure was removed from the market in 2018.
Since the Supreme Court repealed Roe v. Wade, women have been searching for birth control options to prevent unintended pregnancy, and for young women, the options are even more limited.
As birth control becomes more regulated and less accessible around the country, some young women have made the decision to stop relying on routine contraceptives, making the permanent switch to sterilization.
There are a few types of tubal sterilization procedures for people with uteruses: Essure sterilization, a placed block in the fallopian tube; bilateral salpingectomy, removal of fallopian tubes and tubal ligation. Essure was taken off the market in 2018.
The standard tubal ligation is an outpatient procedure that involves pumping the abdomen full of gas then removing a section of each fallopian tube through a small incision in the abdomen with a thin, lighted tube.
The procedure takes 15 to 20 minutes, according to Dr. Ron Cypher, an OB/GYN in Wexford, Pennsylvania. Patients can resume normal activities quickly.
Cypher recalled performing a tubal ligation on a 21-year-old patient who decided long-acting reversible contraception (LARC) was not for her because she had already had two kids.
The procedure, which is usually covered partially by insurance, is considered simple, safe and effective. However, many doctors do not recommend it and sometimes even deny the procedure to young women due to their own ethics and the permanence of the procedure.
Abbi Mazzocco, 23, is a pharmacy technician and recent graduate from PennWest Edinboro with a bachelor’s of science in biology and health science.
Mazzocco was 13 years old when she first started researching tubal ligation. She was 22 years old when she got the operation.
“It was something I knew I wanted for a very long time,” she said.
There is no federal age requirement to receive sterilization, but many states have an age requirement to sign the consent form. States like Tennessee and California require patients to be at least 21 to sign, and some states like Massachusetts require patients to be at least 18.
In Pennsylvania, women looking to receive tubal ligation must sign a consent form confirming they are over the age of 21, of sound mind and that the operation is something they truly want.
The more research Mazzocco did, the more she was intimidated by the process of getting approval for the operation.
“It seemed like it was a very hard thing to try to do as a woman in the United States,” she said.
Mazzocco said she read other women’s stories about tubal ligation online, which included things like having a certain number of kids, being over 35-years-old or having their husbands sign off to even be considered for the operation.
Some women have invented abusive family members hoping their doctor will empathize with their situation and perform the operation. Many women say they have been referred from physician to physician in search of someone willing to perform the procedure.
After finding out her insurance would help cover the operation, Mazzocco started looking for a doctor who was up to the task. She said she was looking specifically for a physician that was a young woman, and she found who she was looking for at the OB/GYN Associates of Erie.
Mazzocco said that when she arrived at her appointment, she was ready to plead her case. Bringing along a binder full of papers, she prepared as if she would be delivering a presentation.
The American Congress of Obstetricians and Gynecologists (ACOG) recommends doctors provide individualized counseling to patients including conversations about alternatives and permanence.
They also advise against discouraging or refusing the procedure to medically fit patients old enough to consent. These conversations help the patient understand their decision and give doctors insight into their patient’s circumstances.
“I thought I would have to have an arsenal of reasons as to why I wanted to get it done, just to be believed,” she said. “It was actually such a huge relief that it didn’t take much convincing or explaining.”
Her initial appointment took about five minutes, which Mazzocco was not expecting after what she had read online. She explained that her doctor was very supportive and acknowledged that it was Mazzocco’s decision to make.
Even with a doctor supportive of her decision, she could not get the operation right away due to the cost.
“I was waiting until I was in a better position financially to go ahead with the surgery,” she said. “Even though I paid a pretty penny for it out-of-pocket, it was worth it for me in the end.”
Financial restrictions are a common barrier that can stop or prevent patients from receiving sterilization.
The cost of tubal ligation can range from no cost up to $6,000 when including follow-up visits, according to Planned Parenthood. While some insurance companies like Medicaid may cover the procedure in full, it does not mean they will approve the procedure for coverage.
Roadblocks like this cause only about 53% of desired tubal ligations to be completed, according to The New England Journal of Medicine.
Mazzocco said that with her insurance, she had to prove that she tried other contraceptives before her insurance would help assist with the cost.
As of 2018, private health plans and companies that provide employer-based healthcare can opt out of covering the preventive surgeries and contraception, after regulations expanded allowing them to deny coverage based on religious beliefs and moral convictions according to Centers for Medicare and Medicaid Services.
For patients with Medicare, coverage for sterilization is limited to “necessary treatment of an illness or injury,” meaning sterilization will only be covered in life threatening cases, such as removing a uterus because of a tumor, according to Centers for Medicare and Medicaid Services.
Many women seek birth control for a number of reasons: Some may struggle with irregular periods and extreme cramps or suffer from endometriosis, while others use it as a preventative care for ovarian cysts and unintended pregnancies.
Instead of tubal ligation, many doctors recommend LARC methods like intrauterine devices (IUD) or Nexplanon, which goes in the arm. Both can have some side effects but are 99% effective against unintended pregnancies and are easily reversible.
Doctors do not recommend the procedure because of the high rate of regret. An Oklahoma State University study found that 28% of patients feel regret later in life, and another study showed patients under 30 are even more likely to feel regret.
Only 50-80% of patients who get a reversal have successful pregnancies later. Reversal also increases the risk of ectopic pregnancy, which is a life-threatening complication that occurs when a fertilized egg implants outside the uterus.
Patients also may be able to become pregnant again after with in vitro fertilization (IVF), which is a common method of assisted reproduction for people with fertility problems. IVF is also less invasive but more expensive than tubal ligation reversal.
Since Mazzocco was 14-years-old, she was taking routine contraceptives. After trying different birth control methods like the pill and an IUD, she said tubal ligation seemed like the best method of care.
She received the most common type of tubal ligation, bipolar coagulation, which uses an electric current to cauterize sections of the fallopian tubes.
“In plain terms, they burn out the lining of your uterus,” she said. “My ovaries are still intact, and for my fallopian tubes, they cut out a little portion of it and cauterized each end.”
Another type, hysteroscopic tubal ligation, provides access to the fallopian tubes at their insertion point into the uterus through the cervical canal without any incision.
Sterilization is a permanent, but effective form of contraceptive. Sterilization may not be right for everyone, but for people like Mazzocco who don’t want a future with children, it made the most sense.
“Definitely do your research, make sure it’s right for you. It’s not right for everyone,” she said.
Mazzocco said that as of now, she is happy just being a cat mom. After all the years she spent on birth control, she is happy to no longer worry about routine contraceptives. Mazzocco noted that if she ever does change her mind about motherhood, there are plenty of kids that need adopted.
“I did kind of have a tiny feeling of ‘what if this was not the right thing to do’ but I think that’s normal, and I think that’s okay,” she said. “Because deep in my heart, I know it was the right decision for me.”