By Katherine Rivlin, MD, MSc
Associate Professor, Obstetrics and Gynecology, The Ohio State University Medical Center, Columbus
In this retrospective analysis of the 2015-2017 and 2017-2019 National Survey of Family Growth female respondent files, women younger than 30 years of age were more likely to experience sterilization regret compared to women older than 30 years of age. As women got older, sterilization regret decreased, and no other demographic or clinical factors, including race, parity, educational attainment, or medical reasons for sterilization, were associated with regret.
Danvers AA, Evans TA. Risk of sterilization regret and age: An analysis of the National Survey of Family Growth, 2015-2019. Obstet Gynecol 2022;139:433-439.
Female sterilization is highly effective at preventing pregnancy and remains the most commonly used method of birth control in the United States.1 Options for pregnancy following sterilization are costly, bring risk, and are not always successful. Therefore, female sterilization should be considered a permanent procedure.2 Although sterilization is a relatively simple surgical procedure, the permanence of the procedure is an important consideration for both patients and clinicians.
To date, the most robust data on sterilization regret come from the United States Collaborative Review of Sterilization (CREST) study. This large, prospective, multicenter observational study was conducted among women undergoing sterilization between 1978 and 1987.3 The CREST study documented a higher probability of sterilization regret among women younger than 30 years of age at the time of sterilization, as well as among non-white and unmarried women, and women undergoing postpartum sterilization. A 2005 systematic review of sterilization regret also documented that women younger than 30 years of age were twice as likely to experience regret and eight times more likely to undergo a sterilization reversal procedure compared to women older than 30 years of age.4
In recent years, long-acting, reversible contraceptive (LARC) methods, such as intrauterine devices and subdermal implants, have become more widely available to patients. These non-permanent contraceptive methods are equally as effective at preventing pregnancy as permanent sterilization. The number of women choosing sterilization decreased by about 9% between 2008 and 2019.1,5 In addition, the racial disparities among women choosing sterilization has declined, with no disparity measured in data gathered from 2017-2019.5 Given these shifts, Danvers et al aimed to measure the risk of sterilization regret based on age using a contemporary dataset.
The study team used data from the National Survey of Family Growth, a continuous national survey of a representative sample of people ages 15 to 49 years, which queries participants on pregnancy, fertility, and contraception use. They merged female respondent datasets from the years 2015-2017 (5,554 women) and 2017-2019 (6,141 women) for a total of 11,695 female respondents. Of these, 1,635 women reported undergoing female sterilization. After excluding respondents who underwent sterilization before age 18 years or after age 45 years and those with missing data on sterilization or data irregularities, the final analytic sample included 1,549 women. The investigators used desire for sterilization reversal to measure regret. They included respondents who reported ever undergoing surgery to reverse tubal sterilization and those who answered “definitely yes” to the question, “If your tubal sterilization could be reversed safely, would you want to have it reversed?”
The authors examined respondent characteristics that could affect the risk of regret, including age, race, parity, insurance status, highest educational attainment, choosing sterilization for a “medical reason,” and prior experience with LARC methods. They calculated the overall proportion of women with sterilization regret, and the association between regret and demographic characteristics. They performed an age-stratified analysis of the probability of regret for women sterilized from age 21 to 30 years, and age older than 30 years. They also calculated the probability of regret based on time since sterilization. Finally, they used multivariate logistic regression models to estimate the odds of experiencing sterilization regret based on age at the time of sterilization.
The median respondent age was 40 years, with 8% of respondents between 21 and 30 years of age and 92% older than 30 years of age. About 60% were white, 17% were Black, and 26% were Asian. Almost 60% of respondents underwent sterilization between 21 and 30 years of age, with the median age of sterilization at 29 years of age (interquartile range, 21-43 years). Only 5% of respondents had medical reasons for sterilization, and 16% had used LARC at least once.
In total, 10% of respondents experienced sterilization regret. Black women experienced a 15% regret rate, compared to 9% for white women, and 11% for Hispanic women. Only 5% of women with a medical reason for sterilization experienced regret. Women undergoing sterilization before age 30 years were more likely to experience regret than women undergoing sterilization after age 30 years (13% vs. 7%). Regardless of age at sterilization, sterilization regret increased until age 35 years before declining steadily until age 45 years. In multivariate logistic regression models, each one-year increase in age at the time of survey resulted in a 12% decrease in the odds of experiencing sterilization regret (P < 0.001). Other than age, the survey found no other demographic associations with regret, although Black race approached significance in multivariable regression models (P = 0.059).
COMMENTARY
This study confirms that women who undergo sterilization before age 30 years are more likely to experience regret compared to those older than 30 years of age. Regret decreases in the years following sterilization in all age categories. In contrast, the CREST study documented an increase in regret over time, as well as a much higher overall risk of post-sterilization regret. Although CREST remains the most robust data presently available on regret, the data were collected during a time of national reckoning around sterilization abuse. Participants included in the CREST study may have lacked sufficient information on the permanence of the procedure.
This study documents that age at the time of sterilization matters, even amid common counseling on age as a risk factor for regret and the widespread availability of LARC methods as alternatives to permanent sterilization. The risk of sterilization regret is an important concern to the practicing OB/GYN, particularly given the history of forced sterilization among low-income people and people of color in the United States. In this study, Black respondents trended toward higher levels of regret than their white counterparts, which reflects previously documented trends.6 The American College of Obstetricians and Gynecologists (ACOG) calls “coercive or forcible sterilization practices … unethical [procedures that] should never be performed.”7
Yet, ACOG also recommends that a clinician’s counseling be guided primarily by “respect for an individual[’s] reproductive autonomy.”6 Patients make decisions that are highly personal and influenced by their own lived experiences in ways that cannot be simplified into demographic categories. To deny sterilization to a patient based on a demographic characteristic in an effort to avoid all risk of sterilization regret is to deny that patient personal autonomy. Counseling should acknowledge regret and its risk factors and include all possible alternatives to sterilization, such as LARC methods and partner vasectomy, but ultimately place the patient’s wishes at the center of care.
REFERENCES
- Daniels K, Abma JC. Current contraceptive status among women aged 15-49: United States, 2017-2019. NCHS Data Brief 2020:1-8.
- American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin No. 208: Benefits and risks of sterilization. Obstet Gynecol 2019;133:e194-e207.
- Peterson HB, Xia Z, Hughes JM, et al. The risk of pregnancy after tubal sterilization: Findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161-1168; discussion 1168-1170.
- Curtis KM, Mohllajee AP, Peterson HB. Regret following female sterilization at a young age: A systematic review. Contraception 2006;73:205-210.
- Kavanaugh ML, Jerman J. Contraceptive method use in the United States: Trends and characteristics between 2008, 2012 and 2014. Contraception 2018;97:14-21.
- Shreffler KM, McQuillan J, Greil AL, Johnson DR. Surgical sterilization, regret, and race: Contemporary patterns. Soc Sci Res 2015;50:31-45.
- [No authors listed]. Committee Opinion No. 695: Sterilization of women: Ethical issues and considerations. Obstet Gynecol 2017;129:e109-e116.
