Advancing Sexual and Reproductive Health and Rights
 
International Family Planning Perspectives
Volume 28, Number 4, December 2002
DIGEST

Conflict in a Relationship Before Sterilization May Lead to Desire for Reversal

Only a small minority of women who are protected by contraceptive sterilization express regret about that method choice, regardless of whether they or their husbands have had the surgery, according to findings from a prospective, multicenter U.S. study.1 Within five years after their husbands' vasectomy, 6% of women indicated that it was not a good choice; essentially the same proportion of sterilized women (7%) expressed regret within five years after undergoing tubal occlusion. Women whose relationship was marked by substantial conflict before they underwent tubal sterilization had an elevated likelihood of regretting the decision; conflict also played a role in women's request that either their own or their husbands' sterilization be reversed.

For an in-depth analysis of the five-year cumulative probability of sterilization regret, investigators studied data on 3,672 women aged 18-44 who underwent sterilization between 1985 and 1987 at medical centers in six cities in the United States and 525 women of the same age whose husbands had a vasectomy at centers in five of those cities during the same years. Women were interviewed in person around the time of the surgery; those who completed at least one follow-up phone interview (one, two, three or five years later) and answered a question about sterilization regret were included in the analyses. The researchers calculated life-table estimates of the cumulative probability of regret, of request for reversal and of reversal; they used hazards analysis to assess factors associated with these outcomes.

Women who had undergone tubal occlusion and wives of sterilized men had a number of characteristics in common. Nearly all women in both groups (94-95%) had at least one living child, and more than half (55-59%) said that a year or more had elapsed between their last birth and the sterilization. Nine in 10 cited completion of childbearing as an important reason for sterilization, and two-thirds cited the desire to discontinue other contraceptive use.

In several respects, however, the groups differed significantly. All of the women whose husbands had had vasectomies were married (since this was a criterion for enrollment), compared with 61% of sterilized women. In addition, wives of sterilized men were more likely to be white, were older and better-educated, and were less likely to have had an abortion and to be Medicaid recipients than were women who had undergone tubal occlusion.

Furthermore, whereas nearly three in 10 women in the vasectomy group cited their desire for the procedure as a reason for their husbands' sterilization, in the tubal occlusion group, only half this proportion said that their husbands' desire for the operation was an important factor in the decision. Women in the vasectomy group were less likely than those who had been sterilized to cite financial pressures or other people's opinions about sterilization as reasons for that method choice; they were more likely to believe that a pregnancy would have strained the couple's relationship.

The five-year cumulative probability of regret--i.e., of ever answering no when asked if sterilization was a good choice for the couple or, in the case of tubal occlusion, for the woman herself--was 6% among wives of sterilized men and 7% among sterilized women; the difference was not statistically significant. The probability that the woman requested reversal was the same (2%) in both groups. (One percent of men asked for a vasectomy reversal; the researchers did not ask sterilized women if their husbands or partners had asked them to have the surgery reversed.) Fewer than 1% of sterilized men or women obtained a reversal.

Results of the hazards analysis revealed no significant predictors of regret among women in the vasectomy group. Among sterilized women, however, the analyses identified a number of associations: The likelihood of regret was elevated if the woman had been 30 or younger at the time of the surgery (rate ratio, 2.2), was black (1.6) or reported some or a lot of conflict in the relationship before the sterilization (2.4-3.1); in addition, women who said their husbands or partners had favored sterilization more strongly than they had were more likely to express regret than were those who reported that the partners had had similar feelings about the sterilization decision (2.7). Women who had undergone tubal occlusion because they had completed childbearing or had not wanted to use other contraceptives had a reduced likelihood of regretting their decision when compared with women who did not include these among their reasons for choosing sterilization (0.6-0.7).

A second set of hazards analyses showed no significant associations between the reasons women cited for choosing sterilization and requests for or actually obtaining a reversal. However, conflict in the relationship prior to sterilization was an important factor: In the vasectomy group, the likelihood of a woman's requesting that the procedure be reversed was sharply higher among those reporting a lot of conflict than among those reporting none (rate ratio, 25.3). In the tubal occlusion group, women who reported either some or a lot of conflict had an elevated likelihood of wanting a reversal (2.4 and 5.9, respectively); those who reported some conflict also had elevated odds of actually obtaining one (3.9).

As the researchers note, the study is limited by the small size of the vasectomy group, the lack of information directly from the men represented by that group and the fairly short follow-up period. Citing a study that demonstrated an increasing probability that women would regret their sterilization decision 7-14 years later, they acknowledge that longer-term follow-up could uncover more regret among wives of men who have undergone vasectomy. Nevertheless, they conclude that "most couples who choose sterilization...are satisfied with their decision and do not experience regret." They recommend that when providers counsel men and women about sterilization, they discuss the possibility of regret and, especially, that they emphasize "the desirability of the couple reaching a decision that they are both comfortable with and agree upon."--D. Hollander

REFERENCE

1. Jamieson DJ et al., A comparison of women's regret after vasectomy versus tubal sterilization, Obstetrics & Gynecology, 2002, 99(6):1073-1079.