Because male and female sterilizations are permanent, it is especially important to
counsel clients interested in these methods carefully and allow them to make voluntary,
informed choices. Even the mildest forms of pressuring a client to accept the method
should be avoided.
Most men and women are satisfied with voluntary sterilization, but some clients will
eventually regret their decision to end fertility. Counseling can help reduce the rates of
regret.
Sterilization counseling should involve one-to-one discussions covering the nature of
the procedure, its permanence, possible complications and benefits, and failure rates.
Clients should be informed about alternative long-term methods, and should choose the most
appropriate method for their circumstances. The World Health Organization reports that
sterilization can be used safely at any age, but recommends spending extra time in
counseling younger people.1 Because of the higher risk of
regret and greater likelihood of method failure among young sterilized women, reversible
long-term methods may be more appropriate for couples under age 30.
If sterilization is selected, several topics need to be covered extensively during
counseling, including the risk of complications, how and when to seek emergency treatment,
and the need to use barrier methods to protect against sexually transmitted diseases
(STDs).2
Regret factors
A 1994 FHI review of numerous studies found that estimates vary widely on how many
women will later regret having been sterilized. One study, for example, gave an overall
global range of from 2 percent to 13 percent regret from six months to six years after the
procedure. Levels of regret varied by country and region in the 21 studies analyzed,
typically higher in North America than in developing countries.
However, in contrast to the range of estimates on how many women eventually regret
sterilization, key factors associated with regret were remarkably consistent among the
studies. Young age (under 30) was an important factor in nearly all of the studies.
Allowing others to make the decision, such as a husband or medical personnel; being
sterilized immediately after delivery; a new marriage; and death of a child were also
frequently mentioned factors.3
"You can identify clients who are more likely to experience regret before doing
the procedure," says Dr. Ellen Elizabeth Hardy of the Universidade Estadual de
Campinas in Brazil, who is studying the impact of sterilization on women's lives as part
of FHI's Women Studies Project. "The most important variable in regret is age."
In Brazil, Dr. Hardy and her colleagues interviewed 432 sterilized women and concluded
that requests for reversal operations were very strongly associated with being young
(under 25) at the time of sterilization.4
Women are more likely to be satisfied with sterilization if they are age 30 or older at
the time of sterilization, started having children at a young age, have a desired number
of children, have at least one child of each sex, and are in a stable marriage or
partnership.5 Studies on vasectomy show that regret among men
is also most strongly correlated with having the procedure done at a young age.6
Counseling can encourage careful decisions by clients, helping men and women to
evaluate how they may feel about sterilization in the future if they get divorced, remarry
or lose a child.
"If there is any doubt, providers should encourage couples to go home and think
about it," says Anne Wilson, a Washington-based vice president of the Program for
Appropriate Technology in Health (PATH), which seeks to improve health, especially the
health of women and children. "On the other hand, there are some couples who feel
absolutely sure that sterilization is right for them."
Screening clients for risk of regret does not mean providers should categorically deny
sterilization services to any group of clientele. Sterilization may be appropriate for
some young men and women, and may be their best option, even if not ideal.
"No provider can predict the client's values," says Dr. Amy Pollack,
president of AVSC International (AVSC), an organization based in New York that provides
technical assistance to family planning programs worldwide. "A client's decision
depends on who the client is, her access to resupply [of such contraceptives as the pill],
the couple's circumstances and how they live."
A range of options
Thorough counseling should place a high priority on each client's right to a voluntary
choice from among several good contraceptive options.
Some family planning programs or governments reward couples who select sterilization
with job preference or savings accounts for daughters.7
However, incentives to encourage sterilization may interfere with choice.
"If a provider suspects a client is not making a free, informed decision, he or
she should recommend a long-term reversible method, such as an intrauterine device (IUD),
Norplant or an injectable," says Dr. Sangeeta Pati, medical associate of clinical
services at AVSC. Sometimes couples are not aware that other options are even available,
adds Wilson of PATH.
However, ensuring that couples have fully considered other options can be difficult in
settings where only a few methods are available. Lack of access to alternative methods can
be a form of undue pressure to become sterilized.
The option of sterilization should not be brought up for the first time during labor,
childbirth or abortion, but should be carefully discussed in advance. "We encourage
women who choose sterilization during labor or immediately after childbirth to think it
over carefully, because it is not a good time for them to make a decision," says Dr.
Marta Durand-Carbajal of the Instituto Nacional de la Nutrición Salvador Zubirán in
Mexico City, formerly a visiting researcher at FHI who has performed sterilization and
helped conduct research on regret. "If they are having pain from childbirth, or if
they have just undergone a lot of pain, they might think they do not ever want to go
through that again."
Ensuring adequate time for decision-making is important with any client but may require
more planning with postpartum women. In general, women who get sterilized during or soon
after delivery are more likely to experience regret.8 A Danish
study found that women who waited less time between requesting the operation and getting
it done were also more likely to regret the procedure.9
For men, counseling helps eliminate myths about vasectomy. Incorrect perceptions that
vasectomy will cause impotence, cancer or other health hazards are widespread. Many men
incorrectly equate vasectomy with castration or believe it will cause them to lose
physical strength, develop a higher pitched voice or gain weight. Providers can explain
that sterilization does not affect masculine physical traits or normal sexual function in
any way, and can even improve sexual pleasure by reducing anxieties about accidental
pregnancy or eliminating the need to interrupt lovemaking to use a barrier method.
A study of vasectomized couples conducted in six countries between 1992 and 1995
demonstrated how counseling can counter misunderstandings. Nearly all of the 218 men
interviewed said their concerns about vasectomy were dispelled after talking to providers.
Because most couples chose vasectomy during a pregnancy, the study indicated that a good
time to counsel couples about this male method may be postpartum. Also, counseling women
on vasectomy and teaching them how to discuss vasectomy with their partners in a
non-threatening way may be useful.10
Counseling can also address unfounded fears or myths surrounding female sterilization.
Many women believe that sterilization will cause them to be less feminine, lose their
sexual desire, or gain weight. These myths may stem from the fact that sterilization is
often used by women approaching menopause, a time in life when most women are likely to
gain weight and stop menstruating.
After a choice is made
Once the choice has been made, clients should read, discuss and sign a consent form
prior to the procedure to indicate that they have made a voluntary and fully informed
choice. Men and women should be able to change their decision at any point prior to
surgery.
Clients should be informed that sterilization is permanent because reversal surgery for
men and women is difficult, expensive, not widely available and success is not guaranteed.
Many clients are afraid of the sterilization operation and think it will be painful or
unpleasant. People who know what to expect are more likely to be satisfied. Therefore, a
thorough explanation of the procedure should be given to all clients, including what type
of anesthesia will be used and whether they will feel any pain.
Instructions about what to do after surgery should explain when clients can return to
work, resume sexual relations and when they need to return for a follow-up visit. One
follow-up visit seven days following female sterilization surgery is generally recommended
to check on healing and remove sutures, while no visits are required after vasectomy.
Providers should review the possibility of postoperative complications, such as wound
infection, fever, pain, bleeding or suspected pregnancy, and instruct clients on what to
do and where to go in the event that complications arise. All sterilization users should
be encouraged to seek treatment immediately if they have any of these problems. At the
Hospital Universitario del Valle in Cali, Colombia, providers give all clients printed
forms explaining what to do in case of emergencies, including telephone numbers to call
and report any problems.
Sterilized people who are at risk of STD infections should be encouraged to use barrier
methods correctly and consistently, such as the latex condom. Among people who use one
method for contraception and condoms or another barrier for STD protection, research shows
that correct and consistent barrier method use declines as the effectiveness of the
primary contraceptive increases.11
-- Sarah Keller
References
- World Health Organization. Improving Access to
Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use. Geneva:
World Health Organization, 1996.
- Church CA, Geller JS. Voluntary female sterilization:
number one and growing. Popul Rep 1990;C(10):2.
- Chi I-c, Jones DB. Incidence, risk factors and
prevention of poststerilization regret in women: an updated international review from an
epidemiological perspective. Obstet Gynecol Survey 1994;49(10):722-32.
- Hardy E, Bahamondes L, Osis MJ, et al. Risk factors for
tubal sterilization regret, detectable before surgery. Contraception
1996;54:159-62.
- Chi; Boring CC, Rochat RW, Becerra J. Sterilization
regret among Puerto Rican women. Fertil Steril 1988;49:973-81.
- Clarke L, Gregson S. Who has a vasectomy reversal? J
Biosoc Sci 1986;18:253-69.
- Hapugalle D, Janowitz B, Weir S, et al. Sterilization
regret in Sri Lanka: a retrospective study. Int Fam Plann Perspect 1989;15(1):22-28.
- Chi.
- Thramov I, Kjersgaard AG, Rasmussen, et al. Regret among
547 Danish sterilized women. Scand J Soc Med 1988;16:41.
- Landry E, Ward V. Perspectives from couples on the
vasectomy decision making: a six-country study. Reprod Health Matters. 1997;special
issue:58-67.
- Cates W. Contraception, unintended pregnancies, and
sexually transmitted diseases: why isn't a simple solution possible? Am J Epidemiol 1996;143(4):311-16.
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