Ethical and Legal Considerations for Sterilization Refusal in Nulliparous Women.

We address the ethical and legal considerations for elective tubal sterilization in young, nulliparous women in Canada, with comparison with the United States and the United Kingdom. Professional guidelines recommend that age and parity should not be obstacles for receiving elective permanent contraception; however, many physicians hesitate to provide this procedure to young women because of the permanence of the procedure and the speculative possibility of regret. At the practice level, this means that there are barriers for young women to access elective sterilization; they are questioned or not taken seriously, or their desire for sterilization is more generally belittled by health care professionals. This article argues for further consideration of these requests and considers the ethical and legal issues that arise when preventing regret is prioritized over autonomy in medical practice. In Canada, there is a paucity of professional guidelines and articles offering practical considerations for handling such requests. Compared with the U.S. and U.K. policy contexts, we propose a patient-centered approach for practice to address requests for tubal sterilization that prioritizes informed consent and respect for patient autonomy. We ultimately aim to assure physicians that when the conditions of informed consent are met and documented, they practice within the limits of the law and in line with best ethical practice by respecting their patients' choice of contraceptive interventions and by ensuring their access to care.

The Role of Social Networks, Medical-Legal Climate, and Patient Advocacy on Surgical Options: A New Era.

The dissemination of information online and resultant public discourse through social media and other online channels has influenced the practice of medicine in dramatic ways. Physicians have historically worked to develop new techniques and devices for the benefit of their patients. It is only a more recent phenomenon, however, that these tools are either removed or their use is curtailed largely driven by anecdotal reports; passionate, vocal, often media-savvy advocates; and plaintiff attorneys. The use of power morcellation, hysteroscopic tubal sterilization, and mesh in urogynecologic procedures all have been victims of these societal pressures. It is important for health care professionals to be involved in the debate to ensure that public outcry does not unduly influence what we, as clinicians, are able to safely offer our patients. By being better advocates for our field, our instruments, and our patients, we can ensure medical decision-making is driven by good science and not public fervor.

Health care justice and its implications for current policy of a mandatory waiting period for elective tubal sterilization.

Tubal sterilization during the immediate postpartum period is 1 of the most common forms of contraception in the United States. This time of the procedure has the advantage of 1-time hospitalization, which results in ease and convenience for the woman. The US Collaborative Review of Sterilization Study indicates the high efficacy and effectiveness of postpartum tubal sterilization. Oral and written informed consent is the ethical and legal standard for the performance of elective tubal sterilization for permanent contraception for all patients, regardless of source of payment. Current health care policy and practice regarding elective tubal sterilization for Medicaid beneficiaries places a unique requirement on these patients and their obstetricians: a mandatory waiting period. This requirement originates in decades-old legislation, which we briefly describe. We then introduce the concept of health care justice in professional obstetric ethics and explain how it originates in the ethical concepts of medicine as a profession and of being a patient and its deontologic and consequentialist dimensions. We next identify the implications of health care justice for the current policy of a mandatory 30-day waiting period. We conclude that Medicaid policy allocates access to elective tubal sterilization differently, based on source of payment and gender, which violates health care justice in both its deontologic and consequentialist dimensions. Obstetricians should invoke health care justice in women's health care as the basis for advocacy for needed change in law and health policy, to eliminate health care injustice in women's access to elective tubal sterilization.

Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care?

OBJECTIVE: Oregon and federal laws prohibit giving informed consent for permanent contraception when presenting for an abortion. The primary objective of this study was to estimate the number of unintended pregnancies associated with this barrier to obtaining concurrent tubal occlusion and abortion, compared with the current policy, which limits women to obtaining interval tubal occlusion after abortion. The secondary objectives were to compare the financial costs, quality-adjusted life years, and the cost-effectiveness of these policies. STUDY DESIGN: We designed a decision-analytic model examining a theoretical population of women who requested tubal occlusion at time of abortion. Model inputs came from the literature. We examined the primary and secondary outcomes stratified by maternal age (>30 and <30 years). A Markov model incorporated the possibility of multiple pregnancies. Sensitivity analyses were performed on all variables and a Monte Carlo simulation was conducted. RESULTS: For every 1000 women age <30 years in Oregon who did not receive requested tubal occlusion at the time of abortion, over 5 years there would be 1274 additional unintended pregnancies and an additional $4,152,373 in direct medical costs. Allowing women to receive tubal occlusion at time of abortion was the dominant strategy. It resulted in both lower costs and greater quality-adjusted life years compared to allowing only interval tubal occlusion after abortion. CONCLUSION: Prohibiting tubal occlusion at time of abortion resulted in an increased incidence of unintended pregnancy and increased public costs.

Family planning in Brazil: why not tubal sterilisation during childbirth?

Sterilisation is the most desired method of contraception worldwide. In 1996, the Brazilian Congress approved a family planning law that legitimised female and male sterilisation, but forbade sterilisation during childbirth. As a result of this law, procedures currently occur in a clandestine nature upon payment. Despite the law, sterilisations continue to be performed during caesarean sections. The permanence of the method is an important consideration; therefore, information about other methods must be made available. Tubal sterilisation must not be the only choice. We argue that review of this restriction will not contribute to the increase in caesarean sections but will allow for greater sterilisation choice for men and women.

Committee opinion no. 530: access to postpartum sterilization.

Postpartum tubal sterilization is one of the safest and most effective methods of contraception. Women who desire this type of sterilization typically undergo thorough counseling and informed consent during prenatal care and reiterate their desire for postpartum sterilization at the time of their hospital admission. Not all women who desire postpartum sterilization actually undergo the surgical procedure, and women with unfulfilled requests for postpartum sterilization have a high rate of repeat pregnancy (approaching 50%) within the following year. Potentially correctable barriers to obtaining postpartum sterilization include patient and health care provider factors, as well as hospital and health care system issues. Given the consequences of a missed procedure and the limited time frame in which it may be performed, postpartum sterilization should be considered an urgent surgical procedure. In addition, women with government insurance face barriers to sterilization procedures based on cumbersome consent requirements. The differences in the requirements surrounding consent for sterilization procedures based on the type of insurance a patient has must be addressed in order to establish fair and equitable access to sterilization procedures for all women. Policies and procedures that remove barriers to and increase efficiency in performing postpartum sterilization could reduce cancellations of the procedure. Improving consistency in accomplishing desired postpartum sterilization is an important strategy to reduce high rates of unintended pregnancy in the United States.

[Permanent tubal hysteroscopic sterilization]. / Contraception permanente par pose hystéroscopique d'implants tubaires.

Tubal sterilization, of common practice all over the world, has had a quick spread in France since its legalization in 2001 and the income of a new hysteroscopic method. As a matter of fact, France is the second greater country for women having Essure® and the first country where Essure® method forestall surgical tubal ligation. Thus we focus on good practice and update knowledge about Essure® method.

Ruta crítica para la realización de ligadura tubaria: estudio en un hospital público en la ciudad de Buenos Aires / Critical route for the realization of tubal ligation: study at a public hospital in the city of Buenos Aires

La existencia de brechas entre el marco legal en salud sexual y reproductiva y la puesta en práctica en las realidades sanitarias locales de las políticas públicas relativas a la ligadura tubaria en particular constituye un tema crucial para la Salud Pública de la Argentina. Objetivo general: describir los factores que impulsaron u obstaculizaron la ruta crítica que realizaron las mujeres gran multíparas para ejercer el derecho a solicitar la ligadura tubaria. Material y métodos: el diseño fue exploratorio descriptivo. Se realizaron entrevistas en profundidad y se administró un cuestionario sociodemográfico a una muestra intencional de 30 usuarias gran multíparas que solicitaron la anticoncepción quirúrgica durante el período: agosto de 2009 - enero de 2010, en el Área de Salud Sexual y Reproductiva del Hospital Materno Infantil Ramón Sardá de la Ciudad Autónoma de Buenos Aires. Resultados: 17 de las entrevistadas había solicitado la ligadura tubaria previamente. Del total, 22 entrevistadas iniciaron el recorrido cursando un embarazo no deseado y 9 pensaron en recurrir a un aborto inseguro, entre las cuales 5 averiguaron al respecto y 1 lo intentó. Conclusiones: Se espera que los resultados sean de utilidad para el diseño de estrategias intersectoriales efectivas que permitan monitorear el cumplimiento de la ley nacional Nº 26.130 con el fin de garantizar el acceso oportuno a la ligadura tubaria, y disminuir las iniquidades relativas a brechas territoriales, institucionales y obstáculos simbólicos y epistemológicos, a nivel sanitario, en la Argentina.

The existence of great gaps between the legal frame of the sexual and reproductive health system and the implementation of public policies in relation to tubal sterilization within the reality of local health institutions is a matter of crucial issue for Public Health of Argentina. General objective: To describe the factors that motivate or prevent the beginning of the critical path that grand multiparous women took in order to excercise their right to petition tubal sterilization. Methods and materials: The design was descriptive exploratory. Interviews in depth were conducted and a sociodemographic questionnaire was used over an in tentional sample of thirty grand multiparous women who arrived to the Reproductive and Sexual Health Area of the Ramón Sardá Hospital in the City of Buenos Aires asking for tubal sterilization during August 2009-January 2010. Results: 17 women had preaviously asked for tubal sterilization, and 22 out of the total number initiated the whole process with an unwanted pregnancy; and 9 women considered an unsafe abortion, 5 of them did research about it and 1 tried it. Conclusions: It is expected that the results shall be useful for the design and implementation of effective strategies that allow to monitor the enforcement of the national law N° 26.130 for the purpose of guaranteeing access to tubal sterilization, and to decrease inequality in relation to territorial and institutional gaps, as well as symbolic obstacles in Argentina.

State-of-the-art of non-hormonal methods of contraception: V. Female sterilisation.

OBJECTIVE: Systematic review of the literature on the effectiveness and safety of permanent female contraception. MATERIAL AND METHODS: A systematic Medline and Cochrane Library review of the literature on technique, effectiveness, safety and complications of female sterilisation. Keywords used for research were 'female sterilisation', 'tubal occlusion', 'history', 'counselling', 'hysteroscopy', 'laparoscopy', 'complications' and 'effectiveness'. RESULTS: Worldwide over 220 million couples have resorted to either male (nearly 43 million) or female sterilisation (180 million). In this review the different methods of female sterilisation are described and their advantages and disadvantages discussed. Tubal occlusion is carried out via (mini-) laparotomy, laparoscopy or hysteroscopy. The Ovabloc, Essure and Adiana permanent contraception systems make use of the latter route. CONCLUSIONS: Female sterilisation via the transcervical route is an outpatient or office procedure; it is performed under local anaesthesia or even without anaesthesia. Its complication rate is low. It should be preferred to the abdominal procedures provided the equipment and the experience required are available. Counselling should include information on vasectomy for the partner as well as on alternative long-acting reversible contraceptives. The ten-year cumulative pregnancy rate of sterilisation techniques ranges from 0.1 to 3.6 per 1000 procedures. The life-time risk of failure is around 1/200.

[Essure implants for tubal sterilisation in France]. / La pratique française de la pose des implants de stérilisation tubaire Essure.

OBJECTIVES: Law no. 2001-588 of 4 July 2001 liberalised the practice of tubal sterilisation in France, at the same time as a new hysteroscopic method of female sterilization appeared. The growth of this method has been spurred by the reduced need for analgesia, absence of incision and scar, reduced duration of hospitalization and diminution of costs. The aim of this study was to analyse the use of the Essure procedure in France. PATIENTS AND METHODS: This multicentre study covered seven French facilities from January 2004 through June 2006. This study included 1061 attempted placements of the Essure micro-insert, marketed by Conceptus SAS (France). RESULTS: The first placement attempt was successful in 992 cases (94.4%). The success rate for second attempts was 59% (n = 23). Mean VAS was 3,23 +/- 0.19. Ninety-three percent of patients undergoing Essure placement were satisfied or very satisfied. DISCUSSION AND CONCLUSION: Tubal sterilisation with Essure micro-inserts is a reliable and reproducible method that requires a short period of training. In the future, the hysteroscopic pathway will replace the laparoscopic route.