Megan Opherman knew from the time she was 16 years old that she never wanted children.
When she began seeing a gynecologist at 18, she asked about having her fallopian tubes tied for permanent sterilization.
“It was a struggle from the get-go,” she said. “I was told I was too young, that I’d change my mind, that I wasn’t married. I heard everything in the book.”
Opherman eventually sought care from four different gynecologists, always hearing the same things. She said nurses in the medical offices often gave her dirty looks when they knew about her desire for sterilization. Finally, after a job and insurance change at age 26, she found her fifth and current gynecologist from a list of preferred providers in her insurance plan.
“I told her I wanted to go forward with the procedure, and she completely understood where I was coming from,” said Opherman, of Pittsburgh. “She was very open and willing to help me out, and nonjudgmental. She obviously made sure I knew I was secure about my position. It was very refreshing compared to my previous doctors.”
Opherman had a bilateral salpingectomy, a procedure where both of her fallopian tubes were removed. Her doctor preferred that surgery instead of a tubal ligation, where the tubes are cut or blocked, because of research linking the removal procedure to a lower risk of cancer in the remaining tubes.
Today, two years after the surgery, Opherman is pleased. “I had so many judgmental people in my past and if I had listened to them, I probably would have made a different decision,” she said. “I listened to myself, and I am truly happy with my decision.”
Female sterilization in the form of damaging or removing the fallopian tubes is the most common form of birth control for women, according to research published in 2019 showing that 30.2 percent of women in married couples have had it. But women who are unmarried, young, and childless often face obstacles in getting these procedures. And following the June 24, 2022, Supreme Court decision to overturn Roe v. Wade and leave abortion law for states to decide on access, healthcare providers are reporting more requests for female sterilization procedures than ever before, according the Los Angeles Times. The New York Times reports that this also extends to men seeking a vasectomy, a procedure that cuts or damages a man’s vas deferens. The vas deferens are the tubes that carry sperm to the testicles; without a clear path, sperm cannot reach an egg and result in a pregnancy.
In an audio author’s note on the New York Times story on vasectomies, writer Alisha Haridasani Gupta noted that in the week following the story’s publication, the paper received “hundreds of comments on the piece itself and on social media, and a lot of it has to do with the discrepancy between how easy it is for men to get a vasectomy versus a woman to get a tubal ligation,” she said. Social media reaction to a recent story on tubal ligation for permanent pregnancy prevention also included comments to the effect that women have been denied the requested procedure.
How can women overcome these challenges when they are sure that this form of permanent birth control is what they want and need?
The Pushback Against Women Seeking Permanent Birth Control
Multiple women interviewed for this story shared their experiences of being told they could not get their tubes tied when they asked for it. Many said their doctors told them they were too young, even though some were in their mid-thirties when they requested the procedure.
“I had gone to the ER for severe abdominal pain, and it was a very large cyst on my right ovary,” said Rose Swearingen, now 52, of Mesa, Arizona. “I was 33 and knew I was not going to have children at that point. When the surgeon came in for the surgery work up, I asked him if he would do a tubal ligation on my left tube so I didn’t have to take birth control. He told me that I was too young, that I had several years to really decide, and that the only thing I should be worrying about was the issue with my right ovary. I was also in a Catholic hospital and they did not recommend (read: wouldn’t do) a tubal on a 33-year-old unmarried woman. So it didn’t happen and I was in so much pain I didn’t feel like I could argue. I never had the procedure done and after that surgery and complications from it, I didn’t want to go through it again.”
The American College of Obstetricians and Gynecologists’ 2020 guidelines on the ethical issues and considerations of female sterilization state that coercive or forcible sterilization should never happen (especially in light of U.S. history of past involuntary sterilization programs for low income and women of color), and that long-acting reversible contraceptives, such as the IUD, and vasectomy if a male partner is a part of the woman’s life, should be discussed. But they also caution against relying only on religious, institutional or patriarchal mindsets if a patient seeks female sterilization: “It is ethically permissible to perform a requested sterilization in [women who haven’t had children] and young women who do not wish to have children. A request for sterilization in a young woman without children should not automatically trigger a mental health consultation. Although physicians understandably wish to avoid precipitating sterilization regret in women, they should avoid paternalism as well,” the guidelines state.
People who are federally insured through Medicaid face another hurdle: Individuals seeking postpartum sterilization are required to complete a specific consent form and undergo a 30-day waiting period, notes The Lancet. Patients with commercial insurance are typically not subject to the waiting period, “creating a two-tiered system of access that restricts reproductive autonomy to those who can afford it.”
How a Tubal Ligation Conversation Between Doctor and Patient Should Go
Any discussion about female contraception of any kind, in an ideal world, should be between a medical provider and the patient, says Karen Tang, MD, MPH, a gynecologic surgeon at the Center for Gynecologic Surgery at Axia Women’s Health in King of Prussia, Pennsylvania. “The patient should be able to express their goals and priorities and the doctor should make information available so the patient can make an accurate decision for herself,” she said.
Dr. Tang, who is active on social media and produces TikTok videos about all aspects of reproductive health, performs female sterilization procedures for patients and has a video urging users to come see her if their own doctors won’t do them.
“I talk with patients about the risk of regret following the procedure, and also the alternatives, such as reversible birth control — such as an IUD, barrier, or a vasectomy if there’s a male partner,” said Tang. “In the end, the patient should feel like the doctor understands their goals and they should feel supported by their doctor by the decision they have made.”
Tang also talks to patients about how most tubal procedures are irreversible, and about research that has found that the people most likely to regret having tubal procedures are those who are under 30 when the procedure was done. “That study is older, though, and in my experience, the regret is most always when there is a new partner, and that is when the conversation changed,” said Tang. But Tang, one of multiple doctors listed on Reddit under a child-free subthread, said that such online communities typically have discussions about female sterilization procedures and providers who are open to patients who are sure about the decision.
If your practitioner is reluctant to perform the procedure for you, try asking around to see if friends or local connections have had tubal ligation done and if they’d recommend their doctor. It may also be worth looking into “child-free” online communities where the topic is discussed and where you may find leads on potential providers.
Insurance Coverage for Tubal Procedures: What to Know
Since health insurers and plans vary widely, Tang recommends checking with your insurer and provider to find out if your insurer will cover the cost in part or full. Private insurers, Affordable Care Act Marketplace plans, and Medicaid should all cover a tubal procedure as a covered contraceptive benefit, but every plan is different, she says.
Opherman found that her insurer, United Healthcare, would not cover the $20,000 price tag of her bilateral salpingectomy, but would have covered the procedure in full if it were a tubal ligation. Her doctor, who pushed for the bilateral procedure due to its lower cancer risk, advocated for Opherman to get the insurer to cover the cost. Ultimately, Opherman paid about $400 out of pocket for the procedure.
It's a lesson for anyone seeking any kind of care, but especially for those who want a permanent form of female sterilization: Keep pushing for what you need.
“I would tell other women to look for healthcare providers that are willing to listen and act on your behalf,” said Swearingen. “You don’t have to stick with a doctor that makes you feel bad. I learned this being plus-size and a cancer survivor. You have to be your own a**h*** sometimes and not take 'no' for an answer.”