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New data address impact of sterilization
Since about one-fourth of all U.S. women ages 15-44 who have ever married have undergone tubal sterilization,1 chances are that you have counseled women about their permanent contraceptive options.
Family planning providers now have new information on incidence of regret following sterilization. Findings from a large-scale prospective cohort study indicate that the probability of regret is similar for women whose husbands undergo vasectomy to those of sterilized women. However, providers will need to check for conflict between partners; researchers note that when there was substantial conflict between a woman and her husband before vasectomy or tubal sterilization, the probability of subsequent request for reversal was increased.2
In a separate report, researchers found that a majority of women indicated no change in sexual interest (80%) or pleasure (81.7%) after tubal sterilization — but in those who did, women were 10-15 times more likely to report increased rather than decreased sexual interest or pleasure.3
CREST yields new reports
Both publications draw their findings from the U.S. Collaborative Review of Sterilization (CREST), a large-scale U.S. trial encompassing 15 participating medical centers. Women ages 18-44 undergoing tubal sterilization were enrolled in the prospective, multicenter cohort study. (Review the following Contraceptive Technology Update articles for analysis of CREST data: "Sterilization note the cause of menstrual problems," March 2001, p. 30; "Young age a factor in sterilization regret," October 1999, p. 116; "Tubal sterilizations don’t rule out ectopic pregnancy," June 1997, p. 67; "Include new failure rates in reviewing sterilization," August 1996, p. 93.)
In the new report comparing women’s regret after vasectomy versus tubal sterilization, 6.1% of the 525 women whose husbands underwent vasectomy regretted the decision five years later, compared to 7% of the 3,672 women who had a tubal ligation. In addition, the overall cumulative probability that a woman would request to have a tubal ligation reversed was 2.2%, compared with 2.0% of women who requested that their husbands’ vasectomies be reversed.2
Women who reported substantial conflict with their husbands or partners before tubal sterilization were more then three times as likely to regret their decision and more than five times as likely to request a reversal than women who did not report such conflict, report the investigators.2
Investigators asked each woman "When it was decided that your husband would have a vasectomy or you would have a tubal ligation, was there any conflict between you and your husband?" If the woman responded, "yes, some," or "yes, a lot," substantial conflict was determined. The study didn’t ask women to specify the nature of the conflict, so the authors don’t know whether the conflicts were about the sterilization procedures or other matters.
Encourage participation of the male partner in making decisions about sterilization, advises Denise Jamieson MD, MPH with the Division of Reproductive Health of the National Center for Chronic Disease Prevention and Health Promotion in the Atlanta-based Centers for Disease Control and Prevention (CDC). In these counseling sessions, potential areas of conflict regarding decisions about sterilization may be identified, she says.
During the counseling process, talk with patients and their partners regarding marital stability, spousal health, and children’s health.4 To assess these areas, ask, "Are you sure you will want no more children? Is your partner?" and "Are you having any marriage problems?"5 Ask the man or woman if either would regret the loss of fertility if their marriage failed or if their spouse or child should die.4 Identifying such risks should not be a reason for denying sterilization; it indicates that more counseling and discussion of long-term reversible methods are necessary.4
Is sex better?
In the second CREST report, researchers concluded that tubal ligation is unlikely to result in changed sexual interest or pleasure.3 Among those women with change, though, the majority experienced positive sexual effects.
Why do some women experience increased sexual interest or pleasure after sterilization? The removal of fear of unwanted pregnancy or the discontinuation of a birth control method with uncomfortable side effects may be the cause, researchers surmise.
Women with post-sterilization regret were the subgroup most likely to have a negative effect; similarly, women reporting regret were significantly less likely to report increased interest or pleasure. Whether the regret or the decreased sexual interest or pleasure occurred first is unclear, say researchers.
How can family planning providers reduce the risk of regret associated with sterilization?
"Most women who choose tubal sterilization are satisfied with their decision and do not experience regret," says Caroline Costello, MPH, with the CDC’s Division of Reproductive Health of the National Center for Chronic Disease Prevention and Health Promotion. "However, previous CREST study analyses have identified some characteristics that may help practitioners identify women who may be at increased risk for experiencing regret: age younger than 30 years, less than one year since the birth of the youngest child, and spousal/partner conflict over the decision to have tubal sterilization."
1. Abma JC, Chandra A, Mosher WD, et al. Fertility, family planning, and women’s health: New data from the 1995 National Survey of Family Growth (DHHS publication no. PHS 97-1995). Vital Health Stat 1997; 23:1-114.
2. Jamieson DJ, Kaufman SC, Costello C, et al. A comparison of women’s regret after vasectomy versus tubal sterilization. Obstet Gynecol 2002; 99:1,073-1,079.
3. Costello C, Hillis SD, Marchbanks PA, et al. The effect of interval tubal sterilization on sexual interest and pleasure. Obstet Gynecol 2002; 100:511-517.
4. Pati S, Carnigan C, Pollack AE. What’s new with female sterilization: An update. Contemp OB/GYN 1998; 6:91-115.
5. Rinehart W, Rudy S, Drennan M. GATHER Guide to Counseling. Population Reports, Series J. No. 48. Baltimore: Johns Hopkins University School of Public Health, Population Information Program; December 1998.