Review risks, benefits of sterilization option

Sterilization remains the most popular form of contraception in the United States; 30.2% of couples rely on tubal sterilization for birth control, while 18.6% use oral contraceptives.1 What are some of the reasons why female sterilization continues as a leading contraceptive method in the United States?

There are many reasons why women chose a particular contraceptive method, including how well it prevents pregnancy, safety, side effects, their desire for more children, cost, and accessibility, says Alison Edelman, MD, MPH, associate professor and co-director, family planning fellowship in the Department of Obstetrics and Gynecology at Oregon Health & Science University in Portland. Edelman served as a coauthor of a new practice bulletin from the American College of Obstetricians and Gynecologists (ACOG) which looks at the risks and benefits of sterilization.2

“Permanent contraception or female sterilization is an extremely safe and effective method for those women who are done with childbearing,” notes Edelman. “Additionally, permanent contraception is often more accessible to women because the costs are typically covered by insurance, especially immediately following a pregnancy, which has not been the case for many other contraceptive methods.”

Sterilization for women blocks fertilization by cutting or occluding the fallopian tubes to prevent the sperm and egg from uniting.3 Analysis of data from the U.S. Collaborative Review of Sterilization (CREST), a large, prospective, multicenter observational study, found a five-year cumulative failure rate of 13 per 1,000 for aggregated sterilization methods (including laparoscopy and laparotomy).4 The risk of pregnancy persisted for years after the sterilization procedure and varies by occlusion technique and age of the woman, the ACOG bulletin notes. The five-year cumulative failure rate is 14 per 1,000 procedures for the copper T 380A intrauterine device (IUD),5 while the five-year cumulative pregnancy rate for the levonorgestrel-releasing IUD ranges from five to 11 per 1,000 procedures.6-8

Annual failure rates of intrauterine contraception are 0.8% for the copper T380A and 0.2% for the levonorgestrel-releasing IUD. The etonogestrel implant has a 0.05% reported failure rate, the lowest of any contraceptive method.9

Women’s options for extremely safe and effective methods, such as long-acting reversible contraceptive (LARC) methods such as the IUD or subdermal implant, are increasing and becoming more acceptable to women and providers, notes Edelman. Women who are considering permanent contraception also should be counseled regarding these options, as well as vasectomy, as they can achieve similar rates of pregnancy protection, she states. (See box item below for components of presterilization counseling.)

“In fact, rates of female permanent contraception have started to decline in a cohort of women studied in Newcastle [in the United Kingdom] as the rates of IUD use have increased,”10 says Edelman. “I think as women learn more these great choices and as more women use these methods — because women talk to other women about their likes and dislikes — we will see U.S. rates of permanent contraception decline as well.”

Talk before postpartum

In the United States, more than 50% of all tubal sterilizations are performed in the early postpartum period, with sterilization procedures performed after 8-9% of all hospital deliveries.11

Postpartum permanent contraception requires counseling and informed consent prior to labor and delivery. Providers should counsel on postpartum options during prenatal care, when the patient can make a considered decision, review the risks and benefits of sterilization, and consider alternative contraceptive methods. Research indicates that such obstacles as young age and concern for patient regret, the consent process, lack of available operating rooms and anesthesia, and receiving care in a religiously affiliated hospital prevent as many as 50% of women who request postpartum sterilization during their prenatal care from undergoing the procedure before discharge after delivery.12 Risk of repeat, unintended pregnancy within one year of delivery has been reported to be as high as 46.7% for women who requested but did not receive postpartum sterilization.12

Anita Nelson, MD, professor in the Obstetrics and Gynecology Department at the David Geffen School Of Medicine at the University of California in Los Angeles, says, “I think this highlights our responsibilities to these women. If we cannot provide them tubal ligation, we should place an implant before she leaves the hospital; by the time we discover we can’t do her procedure, it is generally too late to place an IUD.”

While many women who choose sterilization for contraception do not regret their decision, clinicians must provide thorough and effective counseling in reducing the possibility of regret. Younger women are at greater risk; a meta-analysis of studies of post-sterilization regret concluded that women who underwent sterilization at age 30 or younger were twice as likely to express regret as women older than age 30 at the time of the procedure.13 Because of the regret issue, LARC methods should be strongly considered if the patient is young, says Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta.

“In this age of rapidly increasing use of long acting reversible contraceptives, it may be wise for a woman to use one of the reversible contraceptives for several years if there is any chance at all that she might change her mind and want to become pregnant in the future, because all of the LARC methods are fully reversible quickly,” notes Hatcher. “Tubal sterilization reversal is extremely expensive and involves a complicated process to reverse.”

References

1. Jones J, Mosher W, Daniels K. Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. Natl Health Stat Rep 2012; 60:1-25.

2. ACOG Practice bulletin no. 133: benefits and risks of sterilization. Obstet Gynecol 2013; 121(2 Pt 1):392-404.

3. Roncari D, Hou, MY. Female and male sterilization. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.

4. Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996; 174:1,161-1,168.

5. Fortney JA, Feldblum PJ, Raymond EG. Intrauterine devices. The optimal long-term contraceptive method? J Reprod Med 1999;4 4:269-274.

6. Luukkainen T, Allonen H, Haukkamaa M, et al. Five years’ experience with levonorgestrel-releasing IUDs. Contraception 1986; 33:139-148.

7. Sivin I, el Mahgoub S, McCarthy T, et al. Long-term contraception with the levonorgestrel 20 mcg/day (LNg 20) and the copper T 380A intrauterine devices: a five-year randomized study. Contraception 1990; 42:361-378.

8. Andersson K, Odlind V, Rybo G. Levonorgestrel-releasing and copper releasing (Nova T) IUDs during five years of use: a randomized comparative trial. Contraception 1994; 49:56-72.

9. Trussell J. Contraceptive failure in the United States. Contraception 2011; 83:397-404.

10. Mattinson A, Mansour D. Female sterilisation: is it what women really want or are alternative contraceptive methods acceptable? J Fam Plann Reprod Health Care 2006; 32(3):181-183.

11. Chan LM, Westhoff CL. Tubal sterilization trends in the United States. Fertil Steril 2010; 94:1-6.

12. Thurman AR, Janecek T. One-year follow-up of women with unfulfilled postpartum sterilization requests. Obstet Gynecol 2010; 116:1,071-1,077.

13. Curtis KM, Mohllajee AP, Peterson HB. Regret following female sterilization at a young age: a systematic review. Contraception 2006; 73:205-210.

Check Pre-sterilization Counseling Components

• Permanent nature of the procedure

• Alternative methods of contraception available (reversible methods, as well as male sterilization)

• Reasons for choosing sterilization

• Screening for risk indictors for regret

• Details of the procedure, including risks and benefits of anesthesia

• The possibility of failure, including ectopic pregnancy

• The need to use condoms for protection against sexually transmitted diseases, including HIV infection

• Need for post-procedure confirmation following transcervical sterilization methods

• Federal and state Medicaid regulations regarding informed consent, including age of the client, circumstances in which consent is obtained, and interval from time of consent to procedure.

Source: Roncari D, Hou, MY. Female and male sterilization. In: Hatcher RA, Trussell J, Nelson AL, et al. Contraceptive Technology: 20th revised edition. New York: Ardent Media; 2011.