Counseling issues in tubal sterilization.

Publication: American Family Physician

Publication Date: 15-MAR-03

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COPYRIGHT 2003 American Academy of Family Physicians

Female sterilization is the most commonly used "modern" contraceptive in the United States. (1,2) The most recent cycle of the National Survey of Family Growth (1995) indicates that 27 percent of women who have chosen to use contraception have opted for tubal sterilization. (1) In the United States, women are three times more likely to undergo sterilization than are men. (1) The widespread prevalence of female sterilization becomes more understandable considering the high incidence of unintended pregnancy. Sterilization is one of the most effective means of preventing unintended pregnancy. (3) Almost 50 percent of all pregnancies each year are unintended, and the majority occur among women who are using contraception. (4) Despite the recent availability of additional, extremely effective, reversible contraceptive methods, demand for sterilization continues from women who desire ongoing contraception that does not contain hormones and does not require periodic or postcoital contraceptive efforts.

In the United States, interval sterilizations are usually same-day procedures performed under general anesthesia in an outpatient facility. (5) Most U.S. women who have undergone sterilization experience either a postpartum minilaparotomy procedure or an interval (timing of the procedure does not coincide with a recent pregnancy) laparoscopic procedure. (6) In October 2002, the U.S. Food and Drug Administration approved Essure, the first transcervical hysteroscopically placed sterilization method. Counseling issues regarding procedural details, permanence of the procedures, sterilization alternatives, benefits, and risks, including sterilization regret, apply equally to abdominal and transcervical approaches. Regardless of the tubal sterilization procedure chosen, the woman should be confident that sterilization is her choice and her best contraceptive option.

Counseling Issues

Counseling for reversible contraceptive methods generally involves clinician and patient dialogue regarding safety, efficacy, potential side effects, and integration of the method into the woman's lifestyle. All health care professionals who counsel women about contraception should recognize the advantages and disadvantages of female sterilization compared with nonpermanent, long-acting methods (Table 1). (3,7-10) Sterilization counseling should include discussing permanence of the method, possibility of future regret, and information about the surgical procedure. Assessment of whether the woman's partner might consider undergoing sterilization rather than the woman also is appropriate (Table 1). (3,7-10)

Whether a reversible method or sterilization is being considered, the goal of clinician-patient dialogue is to ensure that the woman has enough information and time to determine the best method for her at that point in her life. If sterilization is chosen, the clinician should assess, through two-way dialogue, whether the woman has adequately considered the implications of ending her childbearing potential. Each woman's knowledge base, cultural context, and experiences are different; each woman has her own unique contraceptive history and contraceptive requirements. As a facilitator, the clinician should strive to convey information that is medically accurate yet understandable, unbiased, and provided at such a time and in such a manner as to permit sufficient time for patient deliberation. Helpful clinician-patient conversations vary in detail and focus as dictated by individual patient circumstances.

Any woman who has completed childbearing is a potential candidate for sterilization. Parity, once considered important in determining eligibility for sterilization, does not correlate with sterilization regret and is not a reason to deny the procedure. (11,12) While regret is associated with having the procedure performed at ages younger than 30, (11,12) age is not a criterion for procedure eligibility. However, younger age should signal the need for a careful, thoughtful dialogue about how desire for sterilization can change with changing life events.

FEARS AND MISPERCEPTIONS

When assessing the content and context of patient decision-making, open-ended questions tend to provide the most insight into fears and misperceptions about the procedure. For example, the clinician might ask, "What have you heard or read about sterilization?" or "What concerns do you have about the procedure?"

Misperceptions (e.g., "it...

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