Reproductive & Maternal Health Resource Center

Reproductive & Maternal Health Resource Center

Perspective from Sarah Horvath, MD, MSHP
Disclosures: The authors report no relevant financial disclosures.
March 04, 2022
2 min read
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Intrauterine contraception just as effective as tubal ligation, safer

Perspective from Sarah Horvath, MD, MSHP
Disclosures: The authors report no relevant financial disclosures.
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Intrauterine devices and tubal ligation were similarly effective in preventing pregnancy, although the rate of complications was lower with intrauterine contraception, findings of a retrospective cohort study showed.

“This study was prompted by patients who wanted to know how well different contraceptives might work for people like them, as we know that real world experiences often differ from what is initially reported in clinical studies,” Eleanor Bimla Schwarz, MD, MS, chief and professor of the division of general internal medicine at Zuckerberg San Francisco General Hospital and Trauma Center at the University of California, San Francisco, told Healio.

Intrauterine contraceptives were just as effective at preventing pregnancy as tubal ligation, although they were associated with a lower rate of complications. Source: Adobe Stock
Intrauterine contraceptives were just as effective at preventing pregnancy as tubal ligation, although they were associated with a lower rate of complications. Source: Adobe Stock

Tubal ligation is common in the United States, especially for those with low incomes or chronic medical conditions, Schwarz and colleagues wrote in the Journal of General Internal Medicine.

“Compared to privately insured individuals, U.S. patients with public insurance more frequently report a desire for reversal of tubal sterilization,” the researchers continued. “As Medicaid offers only limited coverage of treatment for infertility, it is important that individuals considering permanent contraception are well informed about all of their contraceptive options.”

Establishing a cohort

To compare the efficacy and safety of tubal ligation with other contraceptives, Schwarz and colleagues reviewed California Medicaid claims among patients who had tubal ligation performed or an intrauterine contraception (IUC) placed from Jan. 1, 2008, to Aug. 31, 2014.

They analyzed the incidence rates of pregnancy claims within 12 months, indications of procedural infection and related pain for 23,628 patients with copper IUDs, 35,705 patients with levonorgestrel IUDs and 23,965 patients with laparoscopic tubal ligation.

Pregnancy rates

In an unadjusted analysis, rates of pregnancy per 100 woman-years were similar across the three groups (2.99% for copper IUD; 2.4% for levonorgestrel IUD; and 2.64% for tubal ligation).

In an adjusted analysis, pregnancy rates were similar among patients with copper IUDs and those with tubal ligation (adjusted incidence rate ratio [IRR] = 0.92; 95% CI, 0.82-1.05), but they were lower among patients with levonorgestrel IUDs compared with those with tubal ligations (aIRR = 0.72; 95% CI 0.64–0.82) and those with copper IUDs (aIRR = 0.78; 95% CI, 0.7-0.87).

Incidence of complications

Patients with tubal ligations more commonly had infections (0.35% vs. 2.91%), acute hemorrhage (0.03% vs. 0.8%) and hysterectomy (< 0.01% vs. 3.96%) compared with patients with an IUC. Pelvic, abdominal and genitourinary pain also were more common in patients with tubal ligation more than 6 months after their procedure, although claims of pain decreased across contraceptive types.

According to the researchers, younger patients more frequently had claims of pelvic and abdominal pain. An analysis of racial differences revealed that Asian, Black and Hispanic patients were significantly less likely to report pain, although they were just as likely to have menorrhagia or pelvic inflammatory claims as white patients.

“These findings should reinforce efforts to make sure that people are well educated about all available contraceptive options so they can pick the one that is the best fit for their current stage of life and family plans,” Schwarz told Healio. “It is particularly important for people looking for highly effective, long-term and convenient contraception to be familiar with IUDs and the subdermal contraceptive implant.”

The study’s limitations included having little data on abortion and no data on the type of laparoscopic tubal ligation performed; it could not determine if an IUC was self-removed or expelled in cases of pregnancy; its observational study design; and its lack of long-term enrollment in California Medicaid.

Moving forward, Schwarz and colleagues suggested that studies evaluate the comparative safety and efficacy of long-term contraceptives more than 1 year after implementation.

“The surgical approach used for postpartum tubal ligation differs from what was examined in this study, so studies comparing the safety and effectiveness of immediate postpartum tubal ligation and IUD placement are still needed,” Schwarz said.