This article will review the latest evidence about permanent contraception, discussing epidemiology, evidence for salpingectomy as a preferred method, timing of postpartum and interval, understanding of risk of regret, and continued barriers to access balanced against ongoing risks for coercion.
Key points
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Fallopian tube surgery for permanent contraception has advanced significantly since first reported during a cesarean in 1881.
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Permanent contraception is a frequently used method of contraception, but there are disparities in use and access that need to be noted and addressed.
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Bilateral salpingectomy has emerged as the preferred procedure, especially when performed remote from delivery through laparoscopy, due to its higher contraceptive effectiveness and ovarian cancer risk reduction.
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Providers have a responsibility to minimize barriers to desired contraception, including permanent contraception, while acknowledging the risk of coercion and regret.
Introduction
Contraceptive tubal surgery performed at the time of a cesarean delivery has been reported in the United States since 1881. In the over 140 years since the first procedure was reported, much has evolved about the techniques, indications, and even how we refer to the surgery. To move away from the connotation of sterilization as a coercive process, permanent contraception is now the preferred terminology. The advent and advances in laparoscopy in the 1970s allowed tubal surgery to be more safely uncoupled from deliveries (interval timing) and led to female permanent contraception becoming more common than vasectomy. Hysteroscopic methods of tubal occlusion held promise in the early 2000s, but there are currently no hysteroscopic permanent contraceptive options available in the United States. Early laparoscopic techniques involved occluding or destroying a portion of the fallopian tubes, but electrosurgery advances and more awareness of the role of the tube in ovarian cancer risk reduction has moved practice toward salpingectomy. While copper intrauterine devices and multi-rod subdermal arm implants were previously available, the increase in long-acting reversible contraceptive (LARC) options including the single-rod etonogestrel arm implant and the levonorgestrel intrauterine devices in 2000 increasingly allowed people the option of highly effective long-term contraception without permanence, and the proportion of contracepting people using permanent methods decreased from 32% to 25% from 2008 to 2016.
The United States has a longstanding history of coercive sterilization practices, with ongoing concerns about ensuring truly informed consent and existence of disparities in utilization. The federal government attempted to address some of these concerns regarding coercive practices with federal regulations in 1976, requiring completion of an informed consent process that includes specific forms and a waiting period for patients utilizing public insurance. Unfortunately, while well-intentioned, this requirement has become a barrier to payment and may not serve as much of a protective function as hoped. Expanding further on the effort to reduce coercion and disparities, the Reproductive Justice movement, led by Black women in the late 1990s, helped bring further attention to the reproductive rights of marginalized communities. Through the efforts of the collective of organizations and researchers, awareness of access, coercion, and disparities in contraceptive use has become a focus of broad coalitions. This article will review in more detail permanent contraception epidemiology, the transition to salpingectomy, timing of the procedure (postpartum vs interval), the impact of concern for regret on permanent contraception counseling, and summarize the challenges of balancing barriers to access with the risk of coercion.
Epidemiology
Nearly all individuals who are sexually active will use some form of contraception during their lifetime. Data indicate that over 99% of women report having used at least 1 form of birth control, with an average of 3.4 methods employed over their lifetime. Currently, approximately two-thirds of women aged 15 to 49 are using a contraceptive method, with permanent contraception being the most prevalent primary method (18.1%), followed by oral contraceptive pills (14%), LARCs (10.4%), and male condoms (8.4%). When assessing dual use of contraception, permanent methods rank second only to male condoms in overall use. Younger respondents exhibit the highest rates of overall contraceptive use, dual method use, and condom use, likely reflecting the increased risk of sexually transmitted infections and a greater likelihood of having multiple sexual partners in this age group.
Despite overall popularity, there are significant sociodemographic disparities in which patients choose to use permanent female contraception. As expected, the use of permanent contraception tends to increase with age, with approximately 40% of women aged 40 to 49 utilizing this method for pregnancy prevention, compared to 20% of women aged 30 to 39. Moreover, the use of permanent contraception decreases with higher levels of educational attainment. Among women under 49 years of age, the prevalence of permanent contraception drops from 39.9% for those without a high school diploma or graduate equivalency degree (GED) to 12.1% for women with a bachelor’s degree or higher.
In recent years (as evidenced by Centers for Disease Control and Prevention [CDC] reports for 2017–2019), female permanent contraception did not statistically differ among people of Hispanic origin and other racial groups (19.9% among Hispanic, 18.5% among non-Hispanic White, and 17.6% among non-Hispanic Black women). This contrasts with previous years when differences between these groups were noted. In CDC reports from 2011 to 2015 and 2015 to 2017, the rates of permanent contraception were higher for non-Hispanic Black women compared to their Hispanic or non-Hispanic White counterparts ( Fig. 1 ). , In the United States, Puerto Rican women are the most likely to use permanent contraceptive methods, with nearly one-third opting for these methods.
Stratifying permanent contraceptive choices by marital status reveals notable differences between men and women. In the United States, vasectomies are almost exclusively performed on married men, with never married or previously married men having a significantly lower likelihood of undergoing the procedure (relative risks of 0.1 and 0.3, respectively). Conversely, nearly one-third of permanent contraception procedures are performed on unmarried women, with more than half of these women having never been married at the time of the procedure.
Historically, the trend in female permanent contraception has fluctuated. The advent of laparoscopy in the 1970s led to a sharp increase in the method’s use, peaking in 1977 and stabilizing throughout the 1980s. However, the rate of permanent contraception procedures slightly declined from 687,000 in 1995 to 643,000 in 2006, despite a growing population. Recent evidence suggests that following the US Supreme Court’s decision to overturn Roe v. Wade on June 24, 2022, which removed national protection to abortion access, the rate of permanent contraception procedures is once again increasing for both men and women.
Procedure methods—evidence for salpingectomy
Several methods of tubal permanent contraception ( Fig. 2 ) are available, including tubal occlusion devices, partial salpingectomy, and salpingectomy. The commonly used term “tubal ligation” usually refers to occlusion or partial salpingectomy. These procedures can be performed using laparoscopic, laparotomy (such as during a cesarean section), or mini-laparotomy approaches. In the United States, mini laparotomy is typically reserved for immediate postpartum patients. Although some hysteroscopic methods are used globally, they are no longer available in the United States. These methods, including the Essure method, involved placing a flexible micro-insert device into the Fallopian tube hysteroscopically. This would cause fibrous tissue growth to permanently anchor the device in place and would block off the path of the egg moving through the Fallopian tube into the uterine cavity. Since these methods are not currently in use in the United States, they will not be discussed in detail here.
Recent research has illuminated the distal fallopian tube’s role in ovarian cancer pathogenesis, leading to an increased emphasis on opportunistic salpingectomy as a preventive measure against ovarian cancer. Type II ovarian tumors, known for their aggressive nature and late-stage diagnosis, are responsible for most ovarian cancer-related mortality. Investigation of these tumors has shown that many type II ovarian carcinomas arise in the fallopian tubes, particularly the fimbriae. , Serous tubal intraepithelial carcinomas (STICs) are believed to be precursors to high-grade serous carcinomas of the ovary, fallopian tubes, and peritoneum. Molecular studies have identified a shared TP53 mutation between STICs and high-grade serous carcinomas. Data from the Nurses’ Health Studies have shown that the approximately 30,000 women who underwent tubal ligation had a 24% lower risk of ovarian cancer compared to the nearly 195,000 women who did not. Furthermore, opportunistic salpingectomy has been associated with a 50% to 80% reduction in ovarian cancer risk, compared to a 30% reduction associated with bilateral tubal ligation. , A Markov Monte Carlo simulation model estimated that while salpingectomy incurs slightly higher costs than bilateral tubal ligation, it is more effective in extending life due to reduced ovarian cancer risk, with an incremental cost-effectiveness ratio of $27,278 per life year gained (where costs of <$50,000 is typically accepted as a worthwhile intervention).
Although the efficacy rate of complete bilateral salpingectomy for pregnancy prevention has not been quantified, it is expected to be the most effective form of permanent female contraception due to its complete removal of the pathway between the egg and sperm. Among other methods, the 10-year probability of pregnancy is highest after clip sterilization (36.5/1000), with lower probabilities after unipolar coagulation and postpartum bilateral tubal ligation typically via partial salpingectomy (7.5/1000).
Bilateral salpingectomy also reduces the risk of ectopic pregnancy to nearly 0. In contrast, other methods such as bilateral tubal ligation still carry a risk of ectopic pregnancy if the procedure fails, if there is incomplete closure of the tubes, or reanastomosis or fistula formation occurs. Studies assessing ectopic pregnancy risk with different permanent contraception methods found a 10-year risk of 21.5/1000 for laparoscopic bilateral tubal ligation and 8.4/1000 for laparoscopic electro-destruction of the fallopian tubes. In comparison, salpingectomy (performed via laparoscopy or mini laparotomy) had a risk of 0/1000 procedures. However, in unique populations, like those going through in-vitro fertilization, there have been case reports of ectopic pregnancies following bilateral salpingectomy.
While a more extensive surgical procedure than occlusion or partial salpingectomy, complete salpingectomy has similar safety. One study compared patients undergoing hysterectomy with either bilateral salpingectomy or bilateral tubal ligation, as well as women receiving salpingectomy or bilateral tubal ligation for contraceptive indications. The authors found no differences in need for blood transfusion or readmission to the hospital, although mean operating room time was longer by an average of 10 minutes in the salpingectomy cohorts. Several other studies of salpingectomy versus tubal ligation have also found only small increases in operative time without increased risk of surgical complications, as well as finding that salpingectomy can be completed in the vast majority of cesarean deliveries when the patient desires it. , One study reviewing the National Inpatient Sample between 2015 and 2018 found a small but statistically significant increase in rates of hemorrhage with complete salpingectomy versus bilateral tubal ligation at time of cesarean (3.4% vs 3.0%), although clinical significance is questionable.
The American College of Obstetricians and Gynecologists (ACOG) has recommended opportunistic salpingectomy when performing permanent contraception procedures and at the time of hysterectomy. However, when performing tubal procedures at the time of hysterectomy, the route of uterine removal should not be altered due to the plan to perform opportunistic salpingectomy (for instance, vaginal approach should not be neglected solely to ensure ability to perform salpingectomy). Additionally, education and informed consent of the patient should be at the center of every conversation regarding permanent contraceptive procedures.
Timing of the procedure: postpartum versus interval
Discussions involving the ideal timing of permanent contraception are complex, and there are multiple considerations including feasibility, safety, effectiveness, and convenience. As surgical practices and knowledge have evolved, timing has had less bearing on effectiveness. CREST data (from the Collaborative Review of Sterilization Working Group) showed lower pregnancy rates after postpartum partial salpingectomy at cesarean or after vaginal delivery (7.5/1000) than after the interval laparoscopic application of Hulka clips/Fallope bands (36.5/1000; of note this was prior to Filshie clips). Now that salpingectomy is becoming the standard for permanent contraception due to its effectiveness and risk-reduction benefit, there is no longer a difference in effectiveness based on postpartum versus interval timing of a planned procedure. Additionally, the incidence of complications is the same whether a laparoscopic or immediate postpartum approach is used to perform a permanent contraception procedure. Therefore, it is best practice that patients should have unfettered access to either option, and a patient-centered approach should be used to help patients select the option they desire.
However, many factors impact a patient’s ability to obtain a permanent contraceptive procedure at their desired time. Benefits of permanent contraception in the postpartum periods include technical ease of the procedure (either during a cesarean or mini laparotomy), no need to schedule an additional surgical encounter, potential for use of anesthesia already being used for the cesarean or vaginal delivery, convenience for the patient, and relatively more accessible insurance coverage. However, patients are not always able to receive a postpartum permanent contraceptive procedure, especially following a vaginal delivery. Barriers include limited prenatal care inhibiting comprehensive contraceptive counseling, availability of anesthesia or operating rooms at their delivery institution, insurance coverage, or receiving care at a religiously affiliated hospital unwilling to provide contraception. Other barriers that impact fulfillment of postpartum permanent contraception are time of delivery, body mass index, gravidity, and medical conditions which potentially make the procedure more complicated. , In some studies, as few as 41% to 56% of patients who request postpartum permanent contraception undergo the procedure during the delivery admission.
A major barrier to postpartum permanent contraceptive procedures is a failure to have the required Medicaid Title XIX consent paperwork completed before their delivery. , This form was developed in response to sterilization coercion and a lack of informed consent ( Box 1 ). There is no mandated waiting period for privately insured patients. The modern consequence of this policy aimed to protect poor patients from coercive sterilization practices is that the waiting period and required form can create a barrier to completion of desired permanent contraception. In the 2016 National Statistics Report on Timing and Adequacy of Prenatal Care, patients utilizing Medicaid, Self-Pay, or “other” forms of payment had higher percentages of late or no prenatal care compared to privately insured counterparts (8.6%, 19.8%, 8.2% respectively vs 2.7%).
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