Counseling Issues in Tubal Sterilization

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I. CORI BAILL, M.D., The Menopause Center, Orlando, Florida

VANESSA E. CULLINS, M.D., M.P.H., M.B.A., Planned Parenthood Federation of America, New York, New York

SANGEETA PATI, M.D., Washington, D.C.

Female sterilization is the number one contraceptive choice among women in the United States. Counseling issues include ensuring that the woman understands the permanence of the procedure and knowing the factors that correlate with future regret. The clinician should be aware of the cumulative failure rate of the procedure, which is reported to be about 1.85 percent during a 10-year period. Complications of tubal sterilization include problems with anesthesia, hemorrhage, organ damage, and mortality.

Some women who undergo tubal ligation may experience increased sexual satisfaction. While the procedure is commonly performed postpartum, it can be done readily, without relation to recent pregnancy, by laparoscopy or, when available, by minilaparotomy. Surgery should be timed immediately postpartum, or coincide with the first half of the woman’s menstrual cycle or during a time period when the woman is using a reliable form of contraception. (Am Fam Physician 2003;67:1287-94,1301-2. Copyright© 2003 American Academy of Family Physicians.)

Read the study:

http://www.aafp.org/afp/20030315/1287.html

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TABLE 1
Advantages and Disadvantages of Contraceptive Methods*


Method Advantages Disadvantages Typical use Perfect use
Levonorgestrel implant (Norplant; currently unavailable in the United States)
1. At least 5-year duration of effectiveness; as effective as sterilization for 5 years
2. Prompt return of fertility
3. Other advantages are similar to those listed below for medroxyprogesterone acetate (items 3 through 7)
4. Not dependent on user compliance
1. Minor surgical procedure to initiate and discontinue; requires skilled insertion and removal by physician
2. High initial cost
3. Contour of implant may be visible through skin.
4. Some patients experience “nuisance symptoms,” such as nausea, poor cycle control, acne, weight gain, and depression.
5. May require more than one year from stopping to resume normal cycle and fertility
6. No protection against STDs of the lower genital tract
7. Slight increase in failure rate if user weighs 90 kg (200 lb) or more
0.05 0.05
Vasectomy
1. Male method
2. Safer and quicker procedure than tubal sterilization
3. Permanent contraception
1. High initial cost
2. Surgical procedure; surgical risks include infection, bleeding, failure
3. Complications are rare.
4. Post-sterilization regret
5. No protection against STDs
6. Permanent
7. Becomes effective several weeks after procedure (when all stored sperm have been ejaculated or absorbed)
0.15 0.1
Medroxy-progesterone acetate/ estradiol cypionate (Lunelle)
1. Highly effective
2. Eventual cycle irregularity
3. Readily reversible
4.
5.
6.
7.
8.
1. Monthly injections
2. Irregular cycles are common initially
3. Some women experience “nuisance symptoms,” such as nausea, poor cycle control, acne, weight gain, and depression.
4. No protection against STDs
To be determined 0.05
Medroxy-progesterone acetate (Depo-Provera)
1. User compliance 4 times per year
2. Highly effective
3. No estrogen-related side effects
4. May decrease episodes of crises in patients with sickle cell disease
5. Cost effective
6. Decreased risk of PID
7. Improves endometriosis
1. Some women experience “nuisance symptoms,” such as nausea, poor cycle control, acne, weight gain, and depression.
2. May require more than one year from stopping to resume normal cycle and fertility
3. No protection against STDs of the lower genital tract
4. May decrease bone density (reversible)
0.3 0.3
Tubal sterilization
1.
2.
3.
4.
5.
6.
7.
8.

1. Permanent contraception 2. Low failure rate/highly effective 3. Decreased risk of PID 4. Decreased risk of ovarian cancer

1.
2.
3.
4.
5.
6.
7.
8.

1. High initial cost 2. Surgical procedure; surgical risks as outlined in article text 3. Risk of tubal pregnancy varies by method 4. Post-sterilization regret 5. No protection against STDs 6. Permanent

0.5 (1.85 at 10 years of cumulative use) 0.5
IUD
1. Ease of compliance
2. Highly effective; as effective as female sterilization
3. 10-year duration of effectiveness (ParaGard); 5-year duration of effectiveness (Mirena)
4. Reduced menstrual bleeding and dysmenorrhea with Mirena
1. High initial cost
2. Proximal increased risk of PID, although not a documented long-term risk
3. Requires skilled insertion and removal by physician
4. Risk of uterine perforation greatest at insertion
5. Pain and bleeding in some users lead to discontinuation in 5 to 15 percent of women.
6. If pregnancy occurs with IUD in place, it may be complicated.
7. Expulsion, especially in first three months of use
8. No protection against STDs
ParaGard: 0.8 Mirena: 0.1 ParaGard: 0.6 Mirena: 0.1
Evra contraceptive patch (0.15 mg norel-gestromin/0.02 mg ethinyl estradiol per day)
1. Once prescribed, use controlled by woman
2. New patch once a week for three weeks, no patch during fourth week; therefore, not coitally-related
3. Cycle regularity
4. Potential for same noncontraceptive benefits listed below for OCPs
1. Prescription required
2. No protection against STDs
3. Possible skin irritation
4. “Nuisance symptoms” such as weight changes, breakthrough bleeding, or breast tenderness
5. Unrecognized patch detachment
6. Slight increase in failure rate if user weighs 90 kg (200 lb) or more
To be determined 0.3
NuvaRing(etonogestrel, 0.12 mg/ethinyl estradiol 0.015 mg per day vaginal ring)
1. Once prescribed, use controlled by woman
2. Worn for three continuous weeks, then removed for menstruation; therefore not coitally-related, undetectable by partner
3. Reduced incidence of nausea andvomiting that can occur with OCP use
4. Cycle regularity
5. Potential for same noncontraceptive benefits listed below for OCPs
1. Requires comfort with vaginal insertion and removal
2. Prescription required. If expelled or removed from the vagina for more than three hours during the three weeks of required intra-vaginal use, another contraceptive should be used until the ring has been in place for seven days.
3. No protection against STDs
4. Possible vaginal irritation
5. Possible changes in character of vaginal discharge
6. “Nuisance symptoms” such as weight changes, breakthrough bleeding, or breast tenderness
7. Unrecognized expulsion of NuvaRing
To be determined 0.3
OCP
1. Readily available
2. Protection against ovarian and endometrial cancer
3. Decreased benign breast disease
4. Relief of dysmenorrhea and iron deficiency anemia
5. Cycle regularity 6. Decreased risk of PID and ectopic pregnancy
6. Improved complexion (decreases acne)
7. Easily reversible
8. Improvement of endometriosis
1. Increased risk of cardiovascular and thromboembolic diseases in smokers older than 35 years
2. May exacerbate migraine headaches
3. Requires daily user compliance
4. Effectiveness can be decreased by other medications (e.g., anti-seizure medications)
5. No protection against STDs
6. “Nuisance symptoms” such as weight gain, breakthrough bleeding, and breast tenderness (less common in current low-dose preparations)
7. Slight increase in failure rate if user weighs 90 kg (200 lb) or more
6 to 8 0.1
Male and female condoms
1. Protection against STDs, including AIDS
2. Available over-the-counter
3. Cost effective
1. Disruption of coitus
2. Compliance variability (“condom roulette”)
3. May break or slip
4. User sensitivity to latex or spermicide
14 to 21 3 to 5
Diaphragm
1. Readily reversible
2. May be inserted up to four hours before intercourse
3. Some protection against STDs
1. Requires highly motivated user
2. Possible user sensitivity to spermicidal creams/gels
3. Yearly replacement
4. Refitting recommended if significant weight gain or loss or intervening childbirth occurs
16 6
Fertility awareness-based method(natural familyplanning)
1. No cost
1. Requires highly motivated user
2. Some techniques depend on cycle regularity
3. Few physicians are knowledgeable in teaching the various techniques
4. No protection against STDs
20 1 to 9
Spermicides
1. Some protection against STDs
2. Available over-the-counter
1. User sensitivity/allergy is possible
2. Fair to poor contraceptive effectiveness
3. Disruption of coitus
4. Compliance variability (“condom roulette”)
29 15

STDs = sexually transmitted diseases; PID = pelvic inflammatory disease; IUD = intrauterine device; OCPs = oral contraceptive pills; AIDS = acquired immunodeficiency syndrome.

*–Listed in ascending order based on typical failure rates.

Information from references 3 and 7 through 10.

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Women may fear long-term complications of tubal sterilizat

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