Patients Face Barriers to Permanent Contraception
August 1, 2023 4 minutes read
For people who want a permanent contraception method, both tubal surgery and vasectomy are safe, highly effective, and result in a quick recovery.1
The chief obstacles are insurance restrictions, finding a clinician who can do the procedure, securing an operating room, religious hospitals’ policies, and inconvenience to patients.
“Permanent contraception is something that will meet the needs of many, many men and women around the world who reached the decision they never want to be pregnant or get somebody else pregnant in the future,” says Jeffrey T. Jensen, MD, MPH, the Leon Speroff endowed professor and vice chair of obstetrics and gynecology at the Oregon Health & Science University School of Medicine. “That’s a universal thing,” he adds. “There are few individuals who — every time they’re thinking about having sex — are thinking about reproduction and having a baby.”
People who have not yet reached their desired family size may keep this window open, but for many individuals, that desired number has been met. “For some individuals, that number is zero — no interest in fertility,” Jensen says.
Women can contribute to society and lead successful and fulfilling lives without giving birth. “I see patients frequently who are using a hormonal IUD, and it’s working great for them, but they still want a permanent method,” Jensen notes. “There’s a cognitive benefit of also accepting a permanent method — it’s a very clear statement that this womb is no longer open for business.”
These are some examples of permanent contraception:
• Fallopian tube surgery. The most common approaches for this type of surgery in the United States are:
- Laparotomy, which is performed at the time of cesarean delivery or immediately postpartum;
- Laparoscopy, which is performed at least six weeks postpartum.1
The drawbacks to tubal surgery include difficulty in restoring fertility if someone later wants to give birth. Reversing tubal surgery may require in vitro fertilization or major surgery. Another drawback is a higher probability of an ectopic pregnancy if the method fails.1
• Salpingectomy. The removal of fallopian tubes can be used as permanent contraception. The procedure is a new option for permanent contraception, and long-term safety data are not available. It is more commonly used to treat fertility problems or tubal disease, including cancer.1,2
“This would appear to be the most effective approach, based on the fact that fallopian tubes are required for transport of fertilized eggs into the uterine cavity,” Jensen says. “It makes sense that it would be more effective than methods that block the tube partially.”
Also, Medicaid and other insurers likely will pay for the procedure, and it is an operation that all gynecologists should be able to perform, Jensen adds.
• Culdoscopy. Clinicians insert a camera into the rectovaginal pouch through an incision in the posterior vaginal area. It is not recommended due to its higher complication rate.
• Hysterectomy. This is major surgery and is discouraged for use solely for contraception due to a higher risk of morbidity than other methods of permanent contraception.
Other than a total hysterectomy or a bilateral salpingectomy, there is a possibility of permanent contraception failing and someone becoming pregnant despite having undergone the procedure. Research shows an expected pregnancy rate of 24-96 per 1,000 patients, depending on the type of procedure. Hysteroscopic procedures have the highest rate, and the laparoscopic silicone band has the lowest rate, research has shown.3-5
Tubal surgeries can be beneficial beyond contraception. For example, transabdominal tubal surgery can protect against ovarian cancer. Researchers found a 39% reduction in the risk of ovarian cancer, and the risk remained low for up to 25 years post-surgery.1,6
• Vas surgery. The most common approach of vasectomy, which is a permanent contraception for men, it uses local anesthesia and does not require a scalpel. It is highly effective, safer, less expensive, and faster in procedure and recovery time than tubal surgery.1
It is a common procedure for urologists, but there are a few drawbacks. First, the surgery does not work as a contraceptive until sperm in the reproductive tract are cleared. Men who do not fully understand that limitation could end up with one more child.
Another drawback is that regret for the decision is high among some patients, and they would be mistaken to believe it is easily reversible. Restoring fertility after vas surgery is expensive and highly technical, and results are not guaranteed.
In the United States, there has been a surge of more men — especially young men without children — seeking vasectomies since the Supreme Court overturned Roe v. Wade in June 2022.7 This trend is worrisome from the perspective of family planning providers and urologists.
“Absolutely, I’m concerned,” says Ranjith Ramasamy, MD, an associate professor of urology at the University of Miami Miller School of Medicine. “What’s going to happen five to six years down the line when all these men are looking to get married? Vasectomy reversal is not covered by insurance.”
While many urologists can perform a vasectomy, far fewer can perform a reversal procedure. “I do a reversal every week,” Ramasamy says. “I can’t imagine what it’s like four to five years down the line.”
REFERENCES
- Hou MY, Roncari D. Permanent contraception. Contraceptive Technology, 21st Edition. 2018.
- Aliabadi T. What is salpingectomy procedure? June 26, 2023.
- Druva SS, Ross JS, Gariepy AM. Revisiting Essure — toward safe and effective sterilization. N Engl J Med 2015;373:e17.
- Walter JR, Ghobadi CW, Hayman E, Xu S. Hysteroscopic sterilization with Essure: Summary of the U.S. Food and Drug Administration actions and policy implications for postmarketing surveillance. Obstet Gynecol 2017;129:10-19.
- Gariepy AM, Creinin MD, Smith KJ, Xu X. Probability of pregnancy after sterilization: A comparison of hysteroscopic versus laparoscopic sterilization. Contraception 2014;90:174-181.
- Green A, Purdie D, Bain C, et al. Tubal sterilisation, hysterectomy and decreased risk of ovarian cancer. Survey of Women’s Health Study Group. Int J Cancer 1997;71:948-951.
- Zhang TR, Able C, Ramasamy R, Kohn TP. United States vasectomy incidence rises after the reversal of Roe v. Wade in a national clinical and claims database. Fertil Steril 2023;120:196-197.
For people who want a permanent contraception method, both tubal surgery and vasectomy are safe, highly effective, and result in a quick recovery. The chief obstacles are insurance restrictions, finding a clinician who can do the procedure, securing an operating room, religious hospitals’ policies, and inconvenience to patients.
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