COMMENTARY

Which Surgical Sterilization Method Is Most Effective?

Peter Kovacs, MD, PhD

Disclosures

January 30, 2018

A Comparison of Three Surgical Contraceptive Methods

To avoid unplanned pregnancies, women can choose from multiple contraceptive methods.[1] The least effective are the calendar and withdrawal methods. Barrier methods improve efficacy and protect against sexually transmitted diseases. Hormonal methods, when used properly, are highly effective and offer numerous noncontraceptive benefits. Long-acting methods are also effective and depend less on user compliance.[1]

Surgical methods are highly effective but are mostly irreversible and therefore are offered to multiparous, "older" women. Data on the various surgical methods are limited in terms of comparative efficacy. To address this gap, a recent register-based study[2] compared the efficacy and safety of three surgical contraceptive methods.

Data from 16,272 sterilization procedures (4425 laparoscopic clipping, 5631 hysteroscopic Essure® procedures, 6216 Pomeroy procedures via laparotomy) were obtained from the Finnish Sterilization Register. The data were linked with information obtained from Induced Abortion and Medical Birth Registers to assess the efficacy of each method.

Patients in the laparotomy group were younger, less likely to be older than age 40 years, and more likely to have three or more previous births. The risk for spontaneous pregnancy after sterilization was lowest in the Essure group (1.97/1000 follow-up years vs 2.5/1000 in the laparoscopic clipping and 2.65/1000 in the Pomeroy groups), although the differences were not significant.

Birth following a spontaneous pregnancy was more likely in the laparoscopy and laparotomy groups than the Essure group. The difference was significant when the Pomeroy and Essure methods were compared (risk ratio, 2.5 [95% confidence interval,1.34-4.67]).

Among the entire cohort, 1394 surgical procedures were performed after sterilization. The Essure group was significantly more likely to undergo surgeries, and hysteroscopies and resterilization were more common in the Essure group.

In summary, all three surgical methods offer similar contraceptive efficacy. Surgery poststerilization is more likely after hysteroscopic Essure device insertion.

Viewpoint

Hysteroscopic sterilization is a minimally invasive, outpatient procedure that offers effective contraception. Contraceptive efficacy is not immediate, however. At 3 months after the intervention, imaging is recommended to confirm placement and tubal blockage. During this 3-month period, another method of contraception is required.[3]

This large register-based study found similar contraceptive efficacy for three different surgical procedures. Some baseline differences in patient groups could have explained differences in the poststerilization spontaneous pregnancy rates; those undergoing laparotomy (Pomeroy procedure) were younger and had higher parity, indicating a higher risk for spontaneous conception. On the other hand, about 30% of the pregnancies in the Essure group were conceived in the first 3 months when the use of another contraceptive method is recommended until placement and tubal blockage are confirmed. After Essure insertion, hysteroscopy may be required for suspected perforation, device dislocation, or abnormal bleeding. This was shown in this study—more hysteroscopies were required than in the other two groups.

A disadvantage of the hysteroscopic approach is that the effect is not immediate, and follow-up testing is required to confirm tubal blockage. Placement is successful in 81%-98% of cases.[4] Current and previous studies found similar efficacy with Essure compared with abdominal surgical sterilizations.[5] As the number of interventions increases, further reports on side effects, complications, and efficacy should become available.[6]

It is important to properly counsel patients about all available contraceptive methods and make decisions with the patient. It is also important to collect further information on side effects and efficacy of all available methods.

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