Declining rates of sterilisation reversal procedures in western Australian women from 1990 to 2008: the relationship with age, hospital type and government policy changes.

BACKGROUND: Female sterilisation is usually performed on an elective basis at perceived family completion, however, around 1-3% of women who have undergone sterilisation elect to undergo sterilisation reversal (SR) at a later stage. The trends in SR rates in Western Australia (WA), proportions of SR procedures between hospital types (public and private), and the effects of Federal Government policies on these trends are unknown. METHODS: Using records from statutory state-wide data collections of hospital separations and births, we conducted a retrospective descriptive study of all women aged 15-49 years who underwent a SR procedure during the period 1st January 1990 to 31st December 2008 (n = 1868 procedures). RESULTS: From 1991 to 2007 the annual incidence rate of SR procedures per 10,000 women declined from 47.0 to 3.6. Logistic regression modelling showed that from 1997 to 2001 the odds of women undergoing SR in a private hospital as opposed to all other hospitals were 1.39 times higher (95% CI 1.07-1.81) and 7.51 times higher (95% CI 5.46-10.31) from 2002 to 2008. There were significant decreases in SR rates overall and among different age groups after the Federal Government interventions. CONCLUSION: Rates of SR procedures in WA have declined from 1990 to 2008, particularly following policy changes such as the introduction of private health insurance (PHI) policies. This suggests decisions to undergo SR may be influenced by Federal Government interventions.

Risk of Sterilization Regret and Age: An Analysis of the National Survey of Family Growth, 2015-2019.

OBJECTIVE: To estimate the risk of sterilization regret based on age at the time of sterilization in a contemporary group of women. METHODS: We conducted a retrospective analysis of cross-sectional data from the 2015-2017 and 2017-2019 National Survey of Family Growth, Female Respondent Files, to estimate the proportion of women who experience sterilization regret. Descriptive statistics were used to describe the population and the proportion with regret. Sterilization regret was defined as someone who either underwent sterilization reversal or who definitely wanted sterilization reversal. Multivariable logistic regression models were used to assess associations with sterilization regret. RESULTS: A total of 1,549 women who underwent sterilization were included in the analysis; 8% were aged 21-30 years, and 92% were aged older than 30 years. Of the participants, 16.9% identified as Black, 22.0% as Hispanic, and 57.2% as White. Most (58.4%) underwent a tubal sterilization procedure between age 21 and 30 years. The cumulative proportion of regret was 10.2% (12.6% for women who underwent sterilization at age 21-30 years and 6.7% for those who underwent sterilization at older than age 30 years). After controlling for covariates including age, race, parity, educational attainment, and medical reason for sterilization, the only variable that had a statistically significant association with regret was age at the time of the interview (P<.001). As women got older, they were less likely to report sterilization regret. CONCLUSION: Younger women experience more sterilization regret. As women get older, sterilization regret decreases. Counseling about sterilization should reveal the unpredictability of future desire, but age alone must not be a barrier to performing sterilization.

Laparoscopic Tubal Re-anastomosis or In Vitro Fertilisation in Previously Ligated Patients: A Comparison of Fertility Outcomes and Survey of Patient Attitudes

INTRODUCTION: We aim to compare live birth rates, cost analysis and a survey of patient attitudes between laparosopic tubal re-anastomosis and in vitro fertilisation (IVF). MATERIALS AND METHODS: A retrospective study was done in a single reproductive medicine and IVF unit in Singapore from January 2011 to December 2016. Previously ligated patients underwent either laparoscopic tubal re-anastomosis or IVF. The primary outcome was first live birth after treatment. Interval to first pregnancy, miscarriage and ectopic pregnancies were also reported. Patients attending the subfertility clinic completed a questionnaire on IVF and tubal re-anastomosis on preferred choice of treatment, before and after reading an information sheet. RESULTS: Twelve patients underwent tubal re-anastomosis while 31 patients underwent IVF treatment. Pregnancy (75.0% vs 35.5%) and live birth (58.3% vs 25.8%) were significantly higher in the tubal surgery group (P <0.05%) after transferring all available embryos in one stimulated IVF cycle. Cost per live birth was lower in the tubal surgery group (SGD27,109 vs SGD52,438). One hundred patients participated in the survey. A majority of patients preferred tubal surgery to IVF (68.2% vs 31.8%) before given information on the procedures, but indicated a preference for IVF (54.6%) to surgery (45.4%) after receiving information on the procedures. CONCLUSIONS: For women less than 40 years of age, desiring fertility after tubal ligation, laparoscopic tubal re-anastomosis offers better live birth rates and cost-effectiveness. Patients in Singapore are equivocal as to their preference after education regarding the choices. Thus, laparoscopic tubal re-anastomosis remains a viable alternative to IVF treatment.

Racial and Ethnic Disparities in Desire for Reversal of Sterilization Among U.S. Women.

Purpose: Racial and ethnic disparities in rates of female sterilization, a prominent method of contraception, have been consistently observed for decades. Such disparities are also evident in subsequent desire for reversal of the procedure. Additional work is needed to better understand these patterns, particularly given the historical context of coercive sterilization patterns in minority and low-income women. Materials and Methods: Two cycles of the National Survey of Family Growth data are pooled (2011-2013 and 2006-2010) and used to estimate odds ratios (ORs) for race and ethnicity, controlling for payment method, age at sterilization, number of long-term partners, and other known covariates. Results: After adjusting for other factors, the odds of desire for reversal were 70% higher (OR 1.70, confidence interval [95% CI] 1.26-2.29) in non-Hispanic (NH) Black and 54% (OR 1.54, 95% CI 1.14-2.08) in Hispanic women compared to their NH White counterparts. In addition, the likelihood of desire for reversal was substantially increased with lower age at sterilization, a higher number of partners, and lower education. Conclusions: Robust findings of desire for reversal among racial and ethnic minorities, taken together with increased desire for reversal on the basis of specific personal characteristics, merit attention to the possibility that disproportionate outcomes reflect a lack of access to desired contraception and an inability to achieve desired fertility goals in marginalized populations.

Identifying women who will request sterilization reversal in a military population.

OBJECTIVE: We sought to identify the characteristics of women in a military population who are likely to seek a tubal anastomosis after a previous bilateral tubal ligation (BTL). METHOD: A written investigational review board-approved questionnaire was administered to 56 women, ages 18-40 years, requesting evaluation for a reversal of a prior BTL and 52 women of the same age range not seeking reversal. The questionnaire identified demographics and relationship characteristics of volunteers at the time of their decision to have a BTL and at the present time. RESULTS: Age 25 years or younger, sterilization due to pressure from a partner, poor marital relationship at the time of the BTL and a new marriage are highly predictive of tubal sterilization regret and a request for sterilization reversal in a military population. In addition, women requesting a tubal anastomosis reported less preoperative counseling on the permanence of a BTL and of the male alternative for permanent female sterilization, vasectomy. CONCLUSION: Women with these characteristics should have extensive counseling before undergoing tubal sterilization.

Regret following female sterilization at a young age: a systematic review.

Women who undergo sterilization may later regret this decision. This systematic review examines whether age at sterilization is associated with poststerilization regret. Using MEDLINE and EMBASE, we identified 19 articles that examined associations between women's age at sterilization and later regret, requests for sterilization reversal and undergoing sterilization reversal or requesting in vitro fertilization (IVF) procedures. Study results showed that the younger women were at the time of sterilization, the more likely they were to report regretting that decision. Women undergoing sterilization at the age 30 years or younger were about twice as likely as those over 30 to express regret. They were also from 3.5 to 18 times as likely to request information about reversing the procedure and about 8 times as likely to actually undergo reversal or an evaluation for IVF. Results of studies that examined risk by continuous age showed a consistent inverse relationship between women's age at sterilization and their likelihood of regretting having had the procedure.

[Intrapartum and interval tubal sterilization]. / Laqueadura intraparto e de intervalo.

BACKGROUND: Brazil is a country with a high prevalence of tubal ligation, which is frequently performed at the time of delivery. In recent years, an increase in tubal reversal has been noticed, primarily among young women. OBJECTIVES: To study characteristics correlated with the procedure, determine frequency of intrapartum tubal ligation, measure patient satisfaction rates and tubal sterilization regret, in a sample of post-tubal patients. METHODS: Three hundred and thirty-five women underwent tubal ligation. The variables studied were related to the procedure: age at tubal ligation, whether ligation was performed intrapartum (vaginal or cesarean section) or after an interval (other than the intrapartum and puerperal period), health service performing the sterilization, medical expenses paid for the procedure, reason stated for choosing the method and causes related to satisfaction/regret: desire to become pregnant after sterilization, search for treatment and performance of tubal ligation reversal. The women were divided into two groups, a group undergoing ligation in the intrapartum period and a second group ligated after an interval, to evaluate the association between variables by using Fisher's exact test and chi-squared calculation with Yates' correction. The study was approved by the Ethics Committee of the institution. RESULTS: There was a predominance of Caucasian women over 35 years of age, married, and with a low level of education of which 43.5% had undergone sterilization before 30 years of age. Two hundred and forty-five women underwent intrapartum tubal ligation, 91.2% of them had cesarean delivery and 44.6% vaginal delivery. In both groups undergoing intrapartum tubal ligation and ligation after an interval, 82.0% and 80.8% reported satisfaction with the method. Although 14.6% expressed a desire to become pregnant at some time after sterilization, consultation regarding sterility occurred in 3.4% and 2.3%, respectively, and one woman underwent tubal reversal. The most frequent reasons for choosing the method were satisfaction with the number of offspring (35.5% and 46.7%) and medical indication (41.6% and 32.2%), respectively. CONCLUSION: The incidence of intrapartum tubal ligation was higher when the last delivery had been a cesarean section. No difference was detected among the groups regarding rates of satisfaction and regret after performance of the sterilization procedure.

Changes in family structure and regret following tubal sterilization.

Tubal sterilization is one of the contraceptive methods whose use has increased the most in Brazil, but a growing number of women have expressed regret after the procedure. A case-control study was conducted at the Centro Integrado de Saúde Amaury de Medeiros (CISAM), Recife, Pernambuco, Brazil, in 1997 to investigate the association between changes in family structure and request for or submittal to surgical reversal of tubal sterilization, comparing 304 sterilized women who had requested or submitted to reversal of tubal sterilization and 304 women who were also sterilized but had not requested, had not submitted to, and who did not wish to submit to reversal. The simple and adjusted odds ratios were estimated using logistic regression. The results of the current study showed that death of children, partners without children prior to the current union, and partner change after tubal sterilization were associated with the request for or submittal to reversal of tubal sterilization. More strict criteria are suggested in the indication of tubal sterilization, including an in-depth profile of the woman requesting tubal sterilization and identification of risk factors for future regret.

Pregnancy after laparoscopic sterilization.

The authors compare their experience with pregnancies after laparoscopic sterilization with thos reported in the literature. When misidentification and luteal phase pregnancies are excluded, the true failure rate for laparoscopic sterilization varies between 0.9 and 6 per 1000 sterilizations, depending in part on the technique used. This rate is similar to that of nonlaparoscopic techniques. The mechanical methods have a slightly higher rate than do the electrical methods. Pregnancies that occur after a method failure have a high risk of being ectopic. Reversal of laparoscopic sterilizations has now been reported with most methods. Reimplantation of the tube into the uterus and microsurgical techniques appear to produce similar results in patients sterilized by electrosurgical methods. Patients sterilized by mechanical methods are best managed by microsurgical reanastomosis.

Characteristics of women who considered or obtained tubal reanastomosis: results from a prospective study of tubal sterilization.

The Collaborative Review of Sterilization is a prospective study of women undergoing tubal sterilization at selected medical centers in the United States. This analysis examined 5817 study participants who were asked whether they had sought information on tubal reanastomosis after their sterilizations and whether they had actually obtained reanastomosis surgery. Characteristics that predicted the likelihood of seeking reanastomosis information were examined in multivariate, logistic regression models that included age, race, number of living children, history of abortion, education, timing of sterilization in relation to pregnancy, initial marital status, and change in marital status. Among the women studied, 6.2% reported that they had sought information on reanastomosis. Women who were younger than 30 years old at the time of sterilization were twice as likely to seek such information as women aged 30-34, and women who had experienced changes in martial status after sterilization were 2.8 times as likely to seek information as women with unchanged marital status. Thirteen women had actually obtained reanastomosis. Compared with the overall study population, these women were more likely to be white, to have lower gravidity, to be younger, and to have experienced changes in marital status.

Profile of women requesting reversal of sterilization.

One hundred consecutive patients requesting reversal of sterilization have been analyzed. At the time of sterilization 52% were 25 years old or under and 89% were 30 years old or under. Fifty-three patients were not in a stable marital relationship. The mean number of children per patient was 2.39. Two-thirds of the 47 patients who underwent pueperal sterilization regretted their decision within the 1st year. Twenty-six percent of the patients felt psychologically adversely affected by the procedure. The reason for requesting reversal of sterilization in the majority (63%) was a change in marital status. Other reasons were crib death (17%), desire for more children (10%), psychologic factors (6%) accidental tragedies (4%).

Characteristics of women requesting reversal of sterilization.

For a definition of the characteristics of women who request reversal of sterilization, 180 such women were compared with 180 women apparently satisfied with sterilization. Women who requested tubal reversal were younger at the time of sterilization, began and completed their families at an earlier age, and were of lower socioeconomic status than those who did not request reversal of sterilization. Women requesting reversal of sterilization had a significantly higher incidence of gynecologic clinic visits after and mental health clinic visits before and after sterilization. Thirty-five women requesting reversal of sterilization were compared with 35 control women by administration of the Minnesota Multiphasic Personality Inventory (MMPI). Higher MMPI scores on the hysteria and psychasthenia scales were noted in women requesting tubal reversal.

Infertility and the physician--patient relationship: a biopsychosocial challenge.

Research to date has not been able to dispel controversy over the question of "psychogenicity" of infertility. Increasing numbers of studies suggest that neuroendocrinological factors play a role in what is most likely a multidetermined condition. Whatever the etiology, and whether infertility occurs spontaneously (e.g., anovulation) or by choice (e.g., surgical sterilization), the physician must be alert to the special needs of the patient, to the environmental setting, and to the intricate interplay between infertility and emotional reaction. The physician-patient relationship as a triadic rather than dyadic relationship introduces unique transference and counter-transference considerations which must be an acknowledged part of evaluation and treatment.

Tubal sterilization. Characteristics of women most affected by the option of reversibility.

In order to determine the types of women whose sterilization decisions would be most affected by the option of reversibility, responses from 1074 randomly selected ob-gyn patients, concerning eventual intention to undergo permanent and hypothetically reversible procedures, were analyzed. Cross-tabulation of the dependent variables with a wide array of socio-demographic and attitudinal characteristics was followed by discriminant function analysis in order to determine which variables had the greatest independent impact on sterilization decisions. Particular attention was given to the shift from initial rejection of sterilization, when permanent, to its acceptance, when reversible. Intention to eventually undergo permanent sterilization is most significantly associated with intention to have no more children, Friends with positive experience with tubal sterilization and educational level other than a Bachelor's degree. Response change among initial rejectors of permanent sterilization is most strongly associated with mixed feelings regarding abortion, age under 35, and dissatisfaction with or ambivalence toward last contraceptive method used. Response change, using the total sample as a base, is most significantly associated with mixed feelings toward abortion, age under 35, and intention to have or unsure about having more children. These variables suggest that reversible sterilization, although important to all sub-groups, is likely to become a solution for women who are ambivalent toward abortion and is most important to those women likely to experience future fertility, including unwanted births.

Incidence, risk factors, and prevention of poststerilization regret in women: an updated international review from an epidemiological perspective.

Tubal sterilization is the world's most commonly used contraceptive method. Even a small proportion of women incurring poststerilization regret would translate into a large number of sufferers. In this review, we examine recent reports on the incidence of, and the risk factors for, posttubal sterilization regret in women and requests for sterilization reversal in both developed countries and less-developed countries. We also consider the implications of our findings in the practical prevention of poststerilization regret and requests for sterilization reversal, and discuss methodological issues.

PIP: Used by approximately 138 million women of reproductive age, tubal sterilization is the world's most popular contraceptive method. Some women, however, regret having undergone the procedure. Curious about the incidence of, and the risk factors for post-tubal sterilization regret in women, as well as requests for sterilization reversal in both developed and developing countries, the authors searched literature through the Popline and Medline databases published on the subject since 1980. Review of studies' findings indicate that poststerilization regret is limited to a small number of women, regardless of their cultural backgrounds or the development stage of the country in which they reside. Young age at sterilization is an universally strong risk factor for regret, while remarriage is a strong risk factor for request of reversal, especially in developed countries and some African countries where remarriage is common. The death of an infant or child is an important risk factor for regret and desire for reversal in less-developed countries. Careful and thorough counseling by service providers is the key to preventing poststerilization regret and request for the reversal of sterilization. It is recommended that service providers avoid making the sterilization decision for women, avoid performing sterilizations immediately after delivery and concurrently with other surgical procedures in "high risk" women, and when practical, use a tubal occlusion technique for sterilization such as clips or rings which causes the least damage to fallopian tubes. The authors close in affirming that sterilization clients should regard the sterilization procedure as irreversible, yet physicians should perform it as if the procedure may one day need to be reversed.

Reversal of female sterilisation: a comparative study.

In 80 women who had reversal of sterilisation, a study was made of their clinical features at the time of sterilisation and of the factors related to successful outcome. Compared with controls at the time of sterilisation, the women requesting reversal were younger, of lower social class and of higher parity; in addition they were more likely to have an unstable relationship and to have been sterilised following a recent pregnancy. After reversal, intrauterine pregnancy occurred in 26/80 (32.5%) and ectopic pregnancy in 6/80 (7.5%), the majority of successful pregnancies occurring in younger women within one year of reversal following a non-destructive method of tubal occlusion. There was no evidence that techniques of management, including the use of an operating microscope, significantly influenced outcome, and controlled trials will be required to establish their efficacy.

PIP: In 80 women who had reversal of sterilization, a study was made of their clinical features at the time of sterilization and of the factors related to successful outcome. Compared with controls at the time of sterilization, the women requesting reversal were younger, of lower social class and of higher parity; in addition they were more likely to have an unstable relationship and to have been sterilized following a recent pregnancy. Only 24% were still in their original marriage. Most of these gave regret as the reason for their request, while the rest had lost children. The remaining women wished reversal because of a change of partner; 2/5 had remarried, while 3/5 were single, widowed, separated or divorced, but cohabiting. It is clear that sterilization at delivery may be in response to severe social pressure, but it may not always be in the patients' longterm interests to yield to such pressure. After reversal, intrauterine pregnancy occurred in 32.5% and ectopic pregnancy in 7.5%, the majority of successful pregnancies occurring in younger women within 1 year of reversal following a non-destructive method of tubal occlusion. There was no evidence that techniques of management, including the use of an operating microscope, significantly influenced outcome; controlled trials will be required to establish their efficacy.

Risk factors for tubal sterilization regret, detectable before surgery.

Brazil has one of the highest prevalence rates of female surgical sterilization in the world. At the same time there is an increased demand for sterilization reversal. In order to understand which women tend to later request reversal of the procedure, a case-control study was carried out comparing 216 women who requested reversal with sterilized women who did not, paired by year of surgery. The relative risk of requesting reversal for women sterilized before age 25 was 18 times that of women sterilized after age 29. The elevated risk remained even after controlling for a number of variables present at the time of surgery. Multiple regression analysis showed that request for reversal was associated with younger age, less information about the procedure, and fewer contraceptive methods known before sterilization. These results support the recommendation that women should be fully informed about the tubal ligation procedure and have access to other contraceptive options before being sterilized.

Prognostic factors for preoperative consultation of women desiring sterilization: findings of a retrospective analysis.

In this exploratory study, 37 sterilized women applying for sterilization reversal were questioned thoroughly to establish why they had decided to undergo sterilization and why they now wished for it to be reversed. Taking an interactive behavioral model as our starting point, we concentrated on the psychosocial circumstances leading to the definitive decision to be sterilized. A relationship crisis at the time of sterilization was found to be a prognostically unfavorable factor. Furthermore, 20 of the 37 patients cited new partnerships as their main reason for seeking reversal. Those who felt pressurized by their gynecologist or partner into undergoing sterilization had significantly more problems in overcoming the psychological stress accompanying such an operation than those who, through a series of consultations on contraception, had had sufficient time and opportunity to make their own decisions. Sterilization performed for medical reasons was found to have particularly problematical consequences, especially where the doctor had made the decision largely on his own, failing to give an adequate explanation for the medical necessity of the operation. Regarding the time chosen for sterilization, the study revealed that the patient's postoperative psychological condition was significantly worse when sterilization was carried out immediately after a delivery, after abortion or after Caesarean section, rather than in the interval between pregnancies. The resulting increase in the incidence of psychosomatic complaints and depressive states is also confirmed in the literature. The findings of this study offer practical suggestions for improved preoperative consultation and should help to determine the course of action to be taken when a patient wishes to be sterilized.

PIP: 37 sterilized women who requested sterilization reversal at the department of gynecology and obstetrics at the University of Cologne in Germany completed a questionnaire on why they chose sterilization and later wanted it reversed. The most common reasons for undergoing sterilization were: a crisis in the relationship with their partner (12), social reasons (7), and birth limiting (7). 3 women had been sterilized without their consent. 11 women, including the 3 who were sterilized without their consent, noted that a 3rd person (partner, physician, mother, girlfriend) was the decisive factor leading to sterilization. Key reasons for applying for sterilization reversal included a new relationship (20), renewed desire to have children with original partner (9), and death of a child (5). 23 of the women had undergone postpartum sterilization. They had a greater feeling of having been manipulated by a 3rd person than those who underwent interval sterilization. Only 11 of the 37 women had wanted their last child before sterilization. 65% of all the women sought counseling from a gynecologist about sterilization. The gynecologist apparently influenced the final decision in about 33% of women. In 60% of cases, the women had gone through with the sterilization without the full consent of their partners. 15 women had suffered from depression requiring drug therapy. 18 women believed that the sterilization produced a negative psychosocial situation, especially among postpartum sterilization cases and those who felt they were coerced to undergo sterilization. Sterilization appeared to have a positive effect on sexual well-being. These findings confirm the importance of extensive preoperative consultation, ideally with both partners, and of the need for the woman to make her own decision without any manipulative influence from a third party.

Evaluation of regret after tubal sterilization.

Many different criteria and profiles have been suggested for the possible cause of regret and requests for reversal after tubal sterilization. Evaluation of data obtained from 2253 women who had undergone tubal sterilization showed a strong correlation between regrets and youthful age and to changes in marital situation. Previously demonstrated risk factors, such as sterilization in connection with abortion or labor were not related to regret in this study material.