Going beyond the blame game: understanding sterilisation and its limits

The Hindu

21-05-2025

The story so far
Recently, the Punjab and Haryana High Court examined a case of a child born after a vasectomy and held, with striking clarity, that conception after sterilisation alone could not be held to brand a surgeon negligent. In Chennai, meanwhile, two separate 'failed' tubectomy cases were fought in the Madras High Court recently where, in one case, a post-sterilisation baby was regrettably called an 'unwanted child', and the court imposed heavy penalties on the State and doctor. And in the other case, the court imposed upon the operating doctor, a fine of ₹60,000. These divergent tones remind us that failure of sterilisation can flow either from human error or from biology—and that the law sometimes struggles to tell the two apart. Hence, there is a need to understand the process behind the procedures.
India's contraceptive landscape
India pioneered the National Family Welfare Programme in 1952 as the first country to do so, yet today, it houses the planet's largest population.More recently however falling fertility levels, at least in the southern States, has indicated that we are in the throes of a demographic shift. Contraception is divided into temporary and permanent methods. Temporary methods include combined oral contraceptives, progestin-only pills, the Copper-T intrauterine device (IUD), the quarterly DMPA injection, and condoms (male and female).
Except for condoms, every other form of contraception is made for women. Yet, that lone male option, the condom, carries a priceless bonus by fending off sexually transmitted diseases (HIV, Hepatitis B, Human Papilloma Virus), a protection its female counterpart cannot provide. Between the 1970s and the present, they helped millions of women prevent unwanted pregnancies and septic abortions, pursue higher education after marriage, allowed women to enter paid work, and, by shrinking household sizes, nudged families towards spending on nutrition and education rather than sheer survival.
Permanent contraception is surgical. There are two routes: tubectomy for women and vasectomy for men. Tubectomy accounts for 98% of permanent sterilisations and contributes to 62% of all contraceptive use among Indian couples. Around 85% of women undergoing tubectomy in India have the procedure performed at a government health facility.
Tubectomy and vasectomy
The fallopian tube—an undulating tunnel of ciliated columnar epithelium and smooth muscle—ferries the ovum toward the womb for embryo formation after intercourse. A tubectomy, done through a mini laparotomy or laparoscopy under spinal or general anaesthesia, severs or seals that conduit. Because the cut is definitive, a woman walks out immediately sterile, yet she continues to menstruate. Usually, it is done during the time of menstruation or immediately within 6 weeks of childbirth. Though it needs an operating theatre, sterile instruments, a skilled surgeon, and an anaesthesiologist, it is still preferred over the far simpler male alternative.
The vas deferens—a cord lined by pseudostratified columnar epithelium with stereocilia and girdled by thick muscle—transports sperm from the testis to the urethra in the penis. A non-scalpel vasectomy, usually under local anaesthesia, takes barely forty minutes, rarely needs a hospital bed and lets the patient resume work the next day and resume sexual activity within a week. The testes keep churning out sperm, but the cells are quietly re-absorbed; erections, libido, and testosterone remain untouched. Two main disadvantages exist in comparison to tubectomy: the man must use condoms for roughly three months while residual sperm clear, and he must return for a semen test—an appointment often sabotaged by stigma, forgetfulness or sheer inertia. However, failures are rare (about 1 in 1,200) compared with tubectomy, which is 1 in 200–300.
Whether the scalpel meets the tube or duct, in all hospital facilities performing the procedure, the following routine happens: due counselling is provided and informed consent is verified; the segment is excised; the labelled specimen travels to histopathology, where ciliated folds confirm fallopian tube or thick muscular wall confirms vas deferens under a microscope. Only after this stamp does the patient receive an incentive—Central funds under the National Family Planning Welfare Programme plus a state 'top-up' because family planning sits on the Concurrent List.
Where does failure occur?
Contraceptive failure, though statistically rare in surgical sterilisation, must be understood through two distinct lenses: medical negligence and medical mal-occurrence. A failure is termed medical negligence when there is a demonstrable breach in the standard of care—such as improper surgical technique, incorrect identification of ligaments over fallopian tubes or ligation of incorrect anatomical structures, non-adherence to aseptic protocols, or lack of adequate postoperative instructions. In such instances, liability may rest with the healthcare provider. In contrast, a failure arising from medical mal-occurrence is one where all protocols were meticulously followed, yet nature intervenes—such as spontaneous recanalisation of the fallopian tubes or vas deferens. These are recognised biological phenomena and cannot be ascribed to incompetence or error. Importantly, under the Medical Termination of Pregnancy (MTP) Act, contraceptive failure is considered a valid legal indication for terminating an unwanted pregnancy. The histopathological examination done after surgery to check the surgically removed parts and identify the tissues acts as a safety barrier for the surgeons and a tipping point for the beneficiaries to rectify.
Paying damages
Since 2013, the National Family Planning Indemnity Scheme has offered a financial net of ₹2 lakh for a death within seven days, ₹50,000 for one in the next three weeks, ₹30,000 for a proven failure, and up to ₹25,000 for major complications. States often stack extra amounts atop these slabs. Doctors, too, are insured up to ₹2 lakh per claim—recognition that good faith cannot always outwit bad luck.
Every year, India performs roughly 5-6 million tubectomies and fewer than 30,000 vasectomies—each stitched under hard fluorescent lights by obstetricians, surgeons and nurses who rarely see the limelight. Their labour has averted an estimated 350-400 million births since 1980, silently enlarging per capita GDP and futures. A few deliveries slip past the scalpel, and courts sometimes use wounding words. But judging by the long arc, the family planning wall still stands tall—solid and pragmatic.
(Dr. C. Aravinda is an academic and public health physician. The views expressed are personal. [e-mail])