Counseling important in sterilization decision
When a woman asks about tubal sterilization, what is your approach?
"When patients present for sterilization, I treat this an opportunity to review their knowledge and attitudes about contraception, as well as their future plans for childbearing," explains Andrew Kaunitz, MD, professor and assistant chair in the obstetrics and gynecology department at the University of Florida Health Science Center/ Jacksonville and director of menopause and gynecology services at the Medicus Women’s Diagnostic Center in Jacksonville.
Some women do not recognize that surgical sterilization is intended to be permanent, notes Kaunitz. If comments such as "the tubes become retied in five years" are offered, the provider must reinforce the permanent nature of sterilization and note it in the patient’s chart, he says.
The term "permanent sterilization" should be explicitly used in patient discussions, states Kaunitz. If that term causes patients discomfort or elicits questions, take the opportunity to explore reversible options, he suggests.
While sterilization is an extremely effective method of contraception, failures do occur, notes Anne R. Davis, MD, assistant professor of obstetrics and gynecology at Columbia University in New York City. Review the findings of the U.S. Collaborative Review of Sterilization (CREST), a multicenter prospective study that examined the sterilization outcomes of more than 10,000 women, and be prepared to discuss them with patients, she says.1
"I think there is concern about the CREST data in terms of the increase in failure rates that were seen with sterilization, which in the long term were more than had been expected," says Vanessa Cullins, MD, MPH, MBA, vice president and medical director of the New York City-based AVSC International. "But what people have to understand is that even at 1.85% overall over 10 years, that cumulative failure rate is much, much lower than the failure rate for most of the reversible methods."
Ectopic pregnancy risk
If a sterilization failure does occur, the risk of an ectopic pregnancy increases, according to the CREST data.2 Failure rates for female sterilization are low, so the actual number of ectopic pregnancies also is quite small. But when pregnancy does occur in a sterilized woman, the risk that it will be ectopic is significant: about one in three. (Contraceptive Technology Update offered an overview of the CREST findings on sterilizations and ectopic pregnancies in June 1997, p. 67.)
The CREST data offer a breakdown of failure rates based on the method used to occlude the tubes. However, because the study was conducted at teaching institutions where providers might have had less experience, it is difficult to generalize the findings as to individual methods.3
Sterilization is an extremely effective procedure in experienced hands, says Cullins. Women who choose sterilization should understand the provider’s experience with his or her preferred method of occlusion. If the provider has good experience and does not have a history of complications in using that particular method, the woman should not worry about the occlusion procedure, she says.
Although most women who were included in the CREST study population expressed no regret after tubal sterilization, women 30 years of age and younger at the time of sterilization had an increased probability of expressing regret during follow-up interviews within 14 years after the procedure.4 (For insight into the CREST data, see CTU, October 1999, p. 116.)
While the vast majority of women do not regret the procedure, it is important to realize that some women do experience such feelings, notes Cullins. Nearly 25% of women with an unreversed tubal ligation in 1995 expressed a desire for reversal of the operation on the part of herself, her husband or partner, or both.5
The most important variable in regret is age, according to Ellen Elizabeth Hardy, PhD, professor in the department of obstetrics and gynecology, school of medical sciences, Universida de Estadual de Campinas in Brazil. Hardy and her colleagues interviewed 432 sterilized women and concluded that requests for reversal operations were strongly associated with youth (under 25) at the time of sterilization.6
While the subject of age is difficult to discuss during counseling, especially when the woman is young and has several children, as is often the case in Brazil, providers must explore the issue with patients, says Hardy.
"Women should be told that young age is a risk factor for regret because young women may experience great changes during the following years of their lives; for example, have a new partner or [experience] death of a child," she notes.
For the woman who is considering tubal sterilization, make sure she has thought through the implications of a change in circumstances and has decided any life change will not alter her satisfaction with her decision, suggests Cullins.
"I think that is the most important thing: that the woman at this point in time in her life is very comfortable with the procedure," Cullins says. "She has not been pressured into the procedure by a husband or partner or physician or people in her family, yet at the same time she has talked to all the people that are important to her in terms of making this decision, and for that particular moment in time she has thought forward, and she does not desire to have any children in the future."
References
1. 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; discussion 1,168-1,170.
2. Peterson HB, Xia Z, Hughes JM, et al. The risk of ectopic pregnancy after tubal sterilization. U.S. Collaborative Review of Sterilization Working Group. N Engl J Med 1997; 336:762-767.
3. Pati S, Pollack AE, Carignan C. What’s new in female sterilization. Patient Care 1999; 33:118-142.
4. Hillis SD, Marchbanks PA, Tylor LR, et al. Poststerilization regret: Findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 1999; 93:889-895.
5. Chandra A. Surgical sterilization in the United States: Prevalence and characteristics, 19651995. National Center for Health Statistics. Vital Health Stat 1998; 20:23.
6. Hardy E, Bahamondes L, Osis MJ, et al. Risk factors for tubal sterilization regret, detectable before surgery. Contraception 1996; 54:159-162.
Providers can order the following print resources:
• Female Sterilization: Answers to Your Questions about Permanent Birth Control (CE-05). Single copies free; 100 copies, $50; 500, $225; and 1,000, $425.
• Permanent Birth Control for Women (CE-02), a low-literacy brochure developed for use in the United States, available in English and Spanish. Single copies free; 100 copies, $20; 500, $90; 1,000, $165.
• Answers to Your Questions about Sterilization Reversal (CE-04). Single copies free; 100 copies, $50; 500, $225; 1000, $425.
To order those resources or for more information on sterilization, contact:
• AVSC International, 440 Ninth Ave., New York, NY 10001. Telephone: (212) 561-8000. Fax: (212) 561-8067. E-mail: [email protected]. Web: www.avsc.org. The Web site offers patient information on female and male sterilization. Please contact by mail or fax prior to order if using a purchase order.
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