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Non-hormonal Contraceptive Methods

(Published July 2013)

Female Sterilization

Operative Sterilization

Description

Female surgical sterilization via tubal occlusion has been used for many years, is highly successful and safe, and has a low risk of complications. The fallopian tubes are occluded by ligation, blocking with clips or rings, or cauterization.

Use

female sterilizationSurgical tubal occlusion may be done as a laparoscopic procedure or as mini-laparotomy. These procedures are usually selected for sterilization after childbirth and can be performed on an outpatient basis as ambulatory surgery. Laparotomy, or an open tubal ligation, requires a hospital stay and is less commonly performed for sterilization purposes.
Because the hormonal milieu is unaffected by these surgeries, women continue to have normal menstrual cycles, and there is no evidence to suggest that the timing of menopause is affected in older women.

After the outpatient procedures, women may resume having sexual intercourse as soon as they feel comfortable.

Effectiveness

This method is effective immediately and has a very low (0.5 percent) failure rate.7

Risks

  • Potential complications associated with anesthesia and surgery.
  • The risk of unintended pregnancy with this method is less than 1 percent.7

Side Effects

  • Some discomfort after surgery.

Contraindications and Precautions

Medical Eligibility Criteria for Operative Female Sterilization
The MEC does not list any categorical contraindications for operative female sterilization but stipulates that known allergy or hypersensitivity to any materials used for the procedure and uncertainty about desire to end fertility would restrict a person’s eligibility.10 Pregnancy or suspected pregnancy, and an inaccessible or difficult-to-access uterus or fallopian tubes and other conditions that place women at high surgical risk, are described as precautions.

Advantages

  • Highly effective
  • Long-term method (considered permanent)
  • Discreet
  • Low risk of side effects
  • After up-front cost, no ongoing cost to maintain method
  • No effect on hormonal milieu
  • Immediately effective; no backup contraception necessary

Disadvantages

  • Requires surgical procedure
  • No protection against STIs

Counseling Messages

  • Tubal occlusion should be considered a permanent end to a woman’s fertility and should not be performed if there is a chance that the patient might desire childbearing in the future.
  • Approximately 20 percent of women who undergo sterilization before age 30 experience regret.15
  • Although procedures for reversal of surgical tubal occlusion exist, reversal is costly and has a low rate of success.
  • This method does not protect against STIs.

Non-operative Sterilization

Description

Non-operative SterilizationTubal microinserts are products for permanent female sterilization.  One is currently available in the US, brand name Essure®,  and a second, brand name Adiana®, was discontinued in April 2012.

Essure consists of two small metal coils around a mesh of polyethylene terephthalate (PET) fibers. When placed in the fallopian tube, the coils expand to hold the device in place and the PET fibers induce an inflammatory reaction. The inflammation stimulates tissue growth in the tubal walls, which occludes the lumen over the following 3–6 months.16

Use

A trained health care provider places the tubal microinserts, usually under local anesthesia or sedation. The hysteroscopic procedure takes about 15 minutes. Hysterosalpingogram is used to verify tubal occlusion about 3 months after the procedure.

Effectiveness

This method is extremely effective:

  • Essure has a failure rate of less than approximately 0.2 percent.17


Risks

Because these sterilization products are new, the long-term effects are not known. Risks include:

  • Perforation of the uterus and/or tube during insertion.
  • Improper placement of the device.
  • The risk of unintended pregnancy with sterilization is 0.2 percent.17,

Side Effects

Side effects of non-surgical tubal occlusion include cramping, pain, and bleeding or spotting on the day of the placement procedure.

Contraindications

Medical Eligibility Criteria for Non-operative Female Sterilization
The MEC does not list any categorical contraindications for non-operative female sterilization but stipulates that known allergy or hypersensitivity to any materials used for the procedure, including to the contrast medium used during the hysterosalpingogram, and uncertainty about desire to end fertility would restrict a person’s eligibility.10 Pregnancy or suspected pregnancy and an inaccessible or difficult-to-access uterus or fallopian tubes are described as precautions.

Other contraindications and precautions include:

    • Taking immunosuppressive medication
    • Previous delivery, miscarriage, or abortion within 6 weeks
    • Current pelvic infection
    • Inaccessible, technically difficult uterus and fallopian tubes
    • Hypersensitivity or allergy to nickel confirmed by a skin test (for Essure only)
    • Unwillingness to use another birth control method for the first 3 months
    • Unwillingness to return 3 months later to check for tubal occlusion
    • Previous tubal ligation

Advantages

  • Highly effective
  • Long-term method (considered permanent)
  • Discreet
  • Low risk of side effects
  • After up-front cost, no ongoing cost to maintain method
  • No effect on hormonal milieu
  • No surgery required

Disadvantages

  • Requires visits to trained clinician for insertion and follow-up hysterosalpingogram
  • Limited data on effectiveness, risks, and side effects
  • No protection against STIs

Counseling Messages

  • Essure is not designed for removal.
  • Tubal occlusion should be considered a permanent end to a woman’s fertility and should not be performed if there is a chance that the patient might desire childbearing in the future.
  • Backup contraception is needed for 3 months or until tubal occlusion is verified.
  • Patients should notify any health care professionals about their microinserts before any intrauterine procedures to avoid damaging the microinserts and other possible risks.
  • Definitive data on effectiveness and risks are not yet available.
  • This method does not protect against STIs.