Study: IUDs Are as Effective as Tubal Ligation — and Safer
Far fewer infections, medical complications
EXECUTIVE SUMMARY
Pregnancy rates are far higher than expected after tubal ligation procedures, researchers found. Hormonal intrauterine devices (IUDs) are safer than tubal ligation, and as effective.
- California Medicaid claims data revealed a rate of 2.64 pregnancies per 100 tubal ligation procedures.
- The same data showed 2.4 pregnancies per 100 IUD insertions.
- Regarding all medical complications, IUDs were safer than tubal ligation.
Researchers made an astonishing discovery when comparing the safety and effectiveness of intrauterine devices (IUDs) and tubal ligation: The rates of pregnancy were similar, and IUDs were much safer.1
Instead of finding pregnancy rates on the order of one in every 1,000 or 10,000 tubal ligation procedures, they found a rate of 2.64 per 100 procedures. For placement of levonorgestrel IUDs the rate was lower — 2.4 per 100 procedures. The rate of pregnancy after insertion of a copper IUD was 2.99 per 100 women.
The most surprising finding was the high number of pregnancies within one year of tubal ligation, says Eleanor Bimla Schwarz, MD, MS, lead study author and professor of medicine and chief of the division of general internal medicine at the University of California, San Francisco School of Medicine.
“People have always thought of tubal ligation as the gold standard, and you’d never get pregnant after one of these procedures,” Schwarz says. “You dig into clinical trials data and quote numbers of 18 pregnancies over 10,000 women over 10 years. Instead, we saw 10 times higher rates.”
Schwarz and colleagues studied California Medicaid claims data of patients who underwent an IUD insertion or a laparoscopic tubal ligation between 2008 and 2014. They excluded procedures performed within 42 days of a birth. In all, 35,705 people received a levonorgestrel IUD, 23,628 patients received a copper IUD, and 23,965 patients underwent laparoscopic tubal ligation. The IUD pregnancies also were higher than expected, but still slightly lower than the pregnancy rates after tubal ligation.
“Usually, we think of IUD pregnancies as one in 1,000, instead of a couple of pregnancies in 100,” Schwarz says. “There’s some sense that pregnancies were known to happen with IUDs, but it’s more surprising that we saw the rates to be so high for the surgical procedure. I think the big takeaway is that if what women are looking for is a highly effective contraception, they don’t have to go for a permanent method to get there.”
Schwarz and colleagues also found that IUDs are many times safer than tubal ligation in terms of infections, bleeding, and other adverse events. For example, IUD infection rates were 0.3% vs. close to 3% for tubal ligation.
The data also revealed nearly 4% of women underwent a hysterectomy after laparoscopic tubal ligation. Hysterectomy rates for women with a copper IUD were zero, and only 0.01% for women with a levonorgestrel IUD.
The medical complications of acute cardiovascular event, deep vein thrombosis or pulmonary embolism, and respiratory complications were three to 10 times higher among the people who underwent tubal ligation vs. IUD placement. Abdominal injuries, acute hemorrhage, and cervical laceration also were many times greater among the tubal ligation group.
“Hemorrhage was also more common — everything was more common,” Schwarz notes. “We looked at how often people went to their doctor for pain — up to a year after the procedure — and the pain was bigger for tubal ligation. It’s a surgical procedure, but those differences persisted even more than six months later when I’d generally expected women to be well-healed.”
Reproductive health providers could use the findings to better inform patients about their contraceptive options, particularly if their goal is to never again become pregnant. The equivalent effectiveness at preventing pregnancy and the much greater safety of IUD options would suggest that most women would benefit from considering an IUD rather than a permanent contraceptive solution. Current research suggests that IUDs can be used long term — more than seven years for hormonal IUDs and 12 years for the copper IUD.
“They offer the possibility of self-removal, retaining autonomy and the ability to make your own decisions,” Schwarz adds. “You don’t have to experience the regret of using a permanent procedure if you change your mind.”
For instance, some people will undergo tubal ligation and later lose a child or end up with a new partner, changing their minds about not becoming pregnant.
“People’s decisions around family size are often very complicated and personal, but they also change,” Schwarz says.
Also, many people who have undergone tubal ligation are lower income, less educated, and experience chronic medical conditions. They may use Medicaid, which offers few services related to fertility treatment. For instance, if someone with tubal ligation decides to become pregnant, in vitro fertilization would not be covered by Medicaid.
These higher-than-expected rates of pregnancy with IUDs and tubal ligation also show the need for abortion care in the United States.
“These findings highlight the fact that unintended pregnancies happen even for people who use highly effective contraception, and abortion can be helpful in protecting women’s health,” Schwarz says.
There are several possibilities for why the Medicaid claims data showed higher rates of pregnancy than expected.
- Other research may have relied on self-reporting, and people may have been less accurate in their reporting of contraceptive use and unintended pregnancy.
- Physicians perform tubal ligations differently, and some methods may have been less effective at blocking the tube.
- People might have removed IUDs on their own, which would not be captured in the database.
“They can pull out an IUD as easily as a tampon,” Schwarz says. “Sometimes the threads are slippery or cut short and people can’t reach them, but if the threads are long, there’s nothing dangerous about it — other than an unintended pregnancy.”
It is important that women who are interested in highly effective contraception know that the most effective options are those that offer some reversibility, such as IUDs and contraceptive implants. Also, male partners should consider vasectomy.
“All of these should be carefully considered to see if they meet the woman’s needs,” Schwarz says. “Tubal ligation should no longer be viewed as the gold standard for pregnancy prevention. Options that preserve patients’ autonomy, such as IUDs, are our goal for reproductive justice and allowing people to have the families they would like, when they would like to have them.”
REFERENCE
- Schwarz EB, Lewis CA, Dove MS, et al. Comparative effectiveness and safety of intrauterine contraception and tubal ligation. J Gen Intern Med 2022 Feb 23;1-8.
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