By Rebecca H. Allen, MD, MPH, Editor
SYNOPSIS: In this Canadian cross-sectional survey of a convenience sample of 844 patients who had undergone female sterilization, the prevalence of regret was 16%.
SOURCE: Rodowa MS, Waddington A, Pudwell J. Regret in the modern contraceptive landscape: Evaluating regret in patients undergoing tubal ligation or bilateral salpingectomy for contraception. J Obstet Gynaecol Can 2024; Jan 24. doi: 10.1016/ j.jogc.2024.102362. [Online ahead of print].
Existing data on regret after permanent sterilization among patients stem mainly from older studies published in the 1980s and 1990s. The authors of this study sought to update estimates of the prevalence of regret among patients who had undergone permanent contraception procedures in Canada, especially in the age of modern long-acting reversible contraceptives, such as intrauterine devices (IUDs) and implants.
The authors performed an electronic cross-sectional survey that was open to Canadians aged 18 to 60 years who had undergone tubal ligation or bilateral salpingectomy for permanent contraception. The survey was advertised on social media sites, such as Twitter, Facebook, and Instagram, and collected a convenience sample of respondents. The survey measured regret with the five-item validated Ottawa Decision Regret Scale and queried demographics, circumstances surrounding regret (if any), and contraceptive history. The survey was available for eight weeks from March 9, 2021, to May 7, 2021.
A total of 844 participants completed the survey. There was no response rate, since the denominator of those who viewed the survey invitation but did not complete the survey is unknown. The majority of respondents (524 [62.1%]) were aged 46 years or older and most had undergone the procedure between the ages of 30-34 years (32.5%) or 25-29 years (26.3%). On a scale from 0 to 100, the mean regret score was 19.3 (standard deviation, 26.3) among all participants and 15.9% strongly agreed or agreed with the statement, “I regret the choice that was made.”
Factors related to increased regret score were younger current age (P = 0.005) and younger age at the time of the procedure (P < 0.001) as well as those who reported the decision for surgery was made primarily by their partner or provider (P < 0.001). Additionally, entering a new relationship since surgery (P = 0.018) and having the procedure performed postpartum (P = 0.002) were associated with higher regret scores. A total of 88 (10.4%) participants reported that they would like to have children or more children, with 30 respondents (3.6%) having tried in vitro fertilization or other procedures to conceive a pregnancy or explored adoption or surrogacy.
COMMENTARY
Permanent contraception is the most commonly used method of contraception among females in the United States (18.1%).1 The authors of this study found that approximately 16% of Canadian patients regretted their procedure, which is similar to the 13% prevalence found in the older U.S. Collaborative Review of Sterilization (CREST) study.2 Also similar to the CREST study is the finding that young age at the time of the sterilization is a risk factor for regret. However, this current study has limitations, in that it may not be generalizable outside of Canada. In addition, as with most electronic surveys that rely on social media for recruitment, there can be sampling bias as to who elects to participate in the survey, as well as an inability to calculate a response rate.
The American College of Obstetricians and Gynecologists (ACOG) has guidelines on how to appropriately counsel patients for permanent contraception.2,3 The provider should counsel patients on the irreversibility of the procedure and regarding the fact that equally effective long-acting reversible methods of contraception exist (IUDs and implants) as well as the option of vasectomy for the partner. Vasectomy is a safer procedure than female permanent contraceptive surgery. It is important for providers to respect patient autonomy and avoid “imposing thresholds based on age or parity or both for permanent contraception.”2 As long as the patient is counseled appropriately about risks (including regret) and benefits, young women or those without children can opt for permanent contraception. In addition, providers should aim to counsel patients in an unbiased manner and not allow preconceived notions regarding race, socioeconomic status, ethnicity, and sexual orientation to influence recommendations for or against permanent contraception as an option. The current study noted that a risk factor for regret was feeling that the provider made the decision for surgery. Therefore, paternalistic treatment of patients should be avoided. The 30-day waiting period required for patients using public health insurance may be interpreted as a barrier or a protection depending on one’s viewpoint.3
It is important to note that the benefits of bilateral salpingectomy for permanent contraception now include the potential decreased risk of ovarian cancer in the future.3 This also should be included in counseling. ACOG states that permanent contraception should not be considered an “elective” procedure but one that is urgent, especially in the postpartum setting where health insurance may be expiring. Barriers to postpartum permanent contraception have been well documented, but hospitals should aim to overcome them for the benefit of patients.2
REFERENCES
- American College of Obstetricians and Gynecologists. Permanent contraception: Ethical issues and considerations. Committee Statement Number 8. Published February 2024. https://www.acog.org/clinical/clinical-guidance/committee-statement/articles/2024/02/permanent-contraception-ethical-issues-and-considerations
- Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: Findings from the United States Collaborative Review of Sterilization. Obstet Gynecol 1999;93:889-895.
- American College of Obstetricians and Gynecologists. Benefits and risks of sterilization. Practice Bulletin Number 208. Published March 2019. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2019/03/benefits-and-risks-of-sterilization
