Is uterine ablation without tubal ligation (tubal sterilization) appropriate for a patient who is not sexually active?

Uterine Ablation Without Tubal Ligation in Non-Sexually Active Patients

Endometrial ablation without tubal ligation is not appropriate for patients who are not sexually active, as ablation alone is not a form of contraception and carries significant risks if pregnancy occurs.1

Risks of Endometrial Ablation Without Sterilization

• Endometrial ablation is not a form of contraception and pregnancy can still occur after the procedure, regardless of sexual activity status at the time of the procedure 1
• Pregnancies following endometrial ablation carry serious risks including:
  • Increased risk of extrauterine pregnancy 1
  • Higher rates of preterm delivery 1
  • Increased risk of stillbirth 1
  • Potential for placenta accreta 2, 3
  • Risk of uterine rupture which can be life-threatening 2
  • Maternal death has been reported 2

Clinical Considerations

• Endometrial ablation irreversibly destroys the uterine lining but does not prevent ovulation or conception 1, 4
• Current sexual activity status may change in the future, creating unexpected pregnancy risk 2, 3
• The American College of Radiology guidelines specifically state that endometrial ablation should only be performed in patients who do not desire future pregnancy 1
• Large population-based studies demonstrate elevated risks of pregnancy complications after ablation 1

Recommended Approach

For patients who are not sexually active but require treatment for abnormal uterine bleeding:

1. If the patient is certain they will never become sexually active in the future:

   • Endometrial ablation with concurrent tubal ligation/sterilization is appropriate 1, 2
   • Hysteroscopic sterilization methods like Essure can be considered for high-risk patients 1

2. If future sexual activity is possible:

   • Endometrial ablation should be combined with tubal sterilization 2, 3
   • Alternative treatments for abnormal uterine bleeding should be considered, such as:
     • Levonorgestrel intrauterine device (more cost-effective with higher quality of life) 4
     • Medical management options 1
     • Hysterectomy for definitive treatment if appropriate 1, 4

Important Complications to Consider

• Postablation-tubal sterilization syndrome can occur in 8.4% of patients who have both procedures, causing cyclic pain months after surgery 5
• Failure to control bleeding may necessitate repeat ablation or hysterectomy 6
• Hematometra (trapped blood in the uterus) can occur after ablation 6
• Endometrial cancer detection may be delayed in post-ablation patients 6

Conclusion for Clinical Practice

When counseling patients about endometrial ablation who are not currently sexually active, clinicians must emphasize that:

• Current sexual activity status is not relevant to the decision about whether tubal ligation should accompany ablation 2, 3
• The potential for future pregnancy and its associated serious risks must be addressed regardless of current sexual activity 2, 4
• Tubal ligation or another reliable form of permanent contraception should be performed concurrently with endometrial ablation to prevent potentially life-threatening pregnancy complications 2, 3