Comparing options for females seeking permanent contraception in high resource countries: a systematic review.

ABSTRACT

BACKGROUND: Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception. METHODS: We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis. RESULTS: Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC. CONCLUSIONS: Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making. SYSTEMATIC REVIEW REGISTRATION PROSPERO [CRD42016038254].

There are multiple options available to help people end their fertility each option with accompanying benefits and risks. A comprehensive comparison of the benefits and risks of available options is important to support informed decision-making. We aimed to understand the comparability of laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and a long-acting reversible contraceptive, the levonorgestrel-releasing intrauterine contraception (LNG-IUC), among females seeking permanent contraception in high resource countries.We followed PRISMA guidelines for conducting systematic reviews. We assessed for risk of bias using the Newcastle­Ottawa scale, to ensure that we were including high-quality studies. We found high variability between the included articles, so we performed a narrative synthesis.We identified 6612 articles and reviewed the full text of 154, of which 34 met our inclusion criteria. We further excluded 10 studies due to high risk of bias and included 24 articles in our synthesis. Most compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. No included studies compared LNG-IUC to other methods. Most comparisons reported effectiveness and adverse events, with fewer reporting tolerability, patient recovery time, non-contraceptive benefits, and costs to the healthcare system. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All options reported adverse events, and all forms of tubal interruption reported a protective effect against cancers.There is insufficient research directly comparing surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception. High-quality studies are needed to support informed decision-making.