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Sterilization - Tubal Ligation

Abstract: Destruction of reproductive organs is prohibited by Jewish Law. The prohibition for men is stronger than that for women. Therefore, vasectomy is not permitted. However, a halachic authority may permit tubal ligation in extreme circumstances, where other methods cannot be used and pregnancy would be a serious health concern.

Discussion: There is a distinct commandment, based on Leviticus 22:24, forbidding sterilization of both people and animals. The prohibition is considered a biblical commandment regarding sterilization of men but only a rabbinic decree regarding sterilization of women. Therefore, there is room for leniency for female sterilization in extraordinary circumstances.

Sterilization differs from other forms of contraception because it is meant to be irreversible. If it were reversible, even in theory, it would be easier to halachically permit. With the existence of the option of re-anastomosis [1] or in vitro fertilization for women post sterilization [2], there are times where sterilization could be permitted. This would be in cases where pregnancy would involve serious health concerns, and other methods of contraception are not possible or would cause significant side effects. However, since one is dealing with a significant halachic prohibition, a question should be asked of a halachic authority. In asking the question it is important to explain why other methods cannot be used and why it is crucial to permanently avoid pregnancy.
There are other factors that should be taken into consideration when choosing a sterilization method. There is a halachic preference to minimize the amount of destruction to the reproductive organs. Therefore, the halachic authority may prefer the use of rings or clips [3]; over cautery or other methods of direct destruction [4]. Similarly, while the final level of damage to the fallopian tubes after microinserts (“coils”) is similar (and thus similarly effective) to that following tubal ligation [5], the destruction is less direct. The other consideration is health risks. One example is the risk of the procedure. Hysteroscopic procedures such as microinserts have the advantage of avoiding the risks of general anesthesia [6]. Total removal of the tube (salpingectomy) [7] has the potential advantage of reduced risk of serous carcinoma, but this would have be balanced against the greater destruction involved.

Implications for Care: Tubal ligation is a last resort for contraception.

If other methods are not possible and pregnancy must be avoided, a rabbi should be consulted.

There may be preference for particular methods of tubal blockage.

Medical References

[1] Hirshfeld-Cytron J1, Winter J. Laparoscopic tubal reanastomosis versus in vitro fertilization: cost-based decision analysis. Am J Obstet Gynecol. 2013 Jul;209(1):56.e1-6.

[2] Malacova E, Kemp A2, Hart R3, Jama-Alol K4, Preen DB5. Success of in vitro fertilization in women with previous tubal sterilization. Contraception. 2015;91:240-4.

[3] Sokal D1, Gates D, Amatya R, Dominik R. Two randomized controlled trials comparing the tubal ring and filshie clip for tubal sterilization. Fertil Steril. 2000 Sep;74:525-33.

[4] Madari S1, Varma R, Gupta J. A comparison of the modified Pomeroy tubal ligation and Filshie clips for immediate postpartum sterilisation: a systematic review. Eur J Contracept Reprod Health Care. 2011 Oct;16(5):341-9.

[5] Sakinci M, Aksu T, Kuru O, Ozekinci M, Sanhal C. Essure microinsert hysteroscopic tubal sterilization: eight-years follow-up results. Clin Exp Obstet Gynecol. 2015;42(1): 72-8.

[6] McMartin K.Hysteroscopic tubal sterilization: an evidence-based analysis. Ont Health Technol Assess Ser. 2013;13(21):1-35.

[7] Lessard-Anderson CR et al. Effect of tubal sterilization technique on risk of serous epithelial ovarian and primary peritoneal carcinoma. Gynecol Oncol. 2014 Dec;135(3):423-7.

Suggested Further Halachic Reading

• Ozarowski J. "Tubal Ligation and Jewish Law: an Overview." Journal of Halacha and Contemporary Society1984; 7:42-52
• Malach D., "Ikur Hatzotzrot." Sefer Assia 1995; 8:121-149
• http://www.daat.ac.il/daat/english/journal/weinreb-1.htm

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