Male or female sterilization: a comparative study*

Transcription

1 FERTILITY AND STERILITY Copyright trj 1989 The American Fertility Society Printed in U.S.A. Male or female sterilization: a comparative study* Anne Grete Kjersgaard, M.D. t Ingrid Thranov, M.D. Ole Vedel Rasmussen, M.D. Jens Hertz, M.D. Department of Surgery, Frederiksborg County Hospital, Hf1rsholm, Denmark The study compares 709 males and 546 females recruited from a well-defined geographic area and sterilized during a 5-year period at the same hospital. Medical records were reviewed and questionnaires sent out. Widespread satisfaction with the sterilization was found. The sterilized women had experienced contraceptive side effects and failures more often than the men. Only 70% of the laparoscopic sterilizations could be carried out during a 1-day admission, 25% of the women complained about long-term sequelae, and there were 1% failures. The vasectomies were carried out on an outpatient basis, there were few postoperative symptoms, and 0.5% failures were recorded. Female sterilization was at least four times as expensive as vasectomy. It is concluded that vasectomy is generally to be preferred to female sterilization, and that the preoperative guidance should involve both man and wife. Fertil Steril51:439, 1989 An increasing number of couples and single persons are choosing sterilization as a method of contraception. The decision to be sterilized can not be taken lightly. First, sterilization involves surgery on a healthy individual, who voluntarily exposes himself or herself to the morbidity of surgery. Second, it is an intervention with far-reaching social and psychological consequences. Only one partner of a couple will need sterilization, but who should it be-the man or the woman? How can the physician guide the couple? Few studies have compared the consequences of male and female sterilization. Smith et al.,l in their study of comparative risks and costs of male and female sterilization based on a literature search, found that the morbidity, the mortality, and the shortterm costs associated with vasectomy were considerably less than those associated with female sterilization. The efficiency rates were found to be sim- Received June 16, 1988; revised and accepted November 1, * Supported by the Danish Medical Research Council. t Reprint requests: Anne Grete Kjersgaard, M.D., Byledet 12, DK-2820 Gentofte, Denmark. ilar. Other aspects such as patient acceptability, regret, etc., were not included. The purpose of the present study was to point out the similarities and differences in the post-sterilization lives of men and women sterilized in the same hospital during a 5-year period, all recruited from a well-defined geographic area, in which there were no other facilities for sterilization. MATERIALS AND METHODS An identical questionnaire was sent to all male and female patients sterilized at the Department of Surgery, Frederiksborg County Hospital, H~rsholm, Denmark, during a 5-year period from January 1, 1978 to December 31, The questionnaire dealt with former use of contraceptives (including side effects and failures), former induced and/or spontaneous abortions and births, and socioeconomic status and family structure, before and after sterilization. The reasons for choosing sterilization, its short- and long-term complications (including changes in sexual life), and regrets also were questioned. The following data were registered from the hos- Kjersgaard eta!. Male or female sterilization 439

2 Table 1 Demographic Characteristics of 1,255 Sterilized Men and Women at the Time of Sterilization Men Women (n = 709) (n = 546) p sterilization (yrs) 36 (25-59) 34 (25-46) NS birth of first child (yrs) 25 (20-52) 21 (15-39) <0.05 birth of last child (yrs) 29 (20-53) 27 (19-40) <0.05 Median no. of children 2 (0-6) 2 (0-4) NS No. of children with present partner 117 (17%) 186 (34%) <0.05 Single parent at sterilization 29 (4%) 84 (15%) <0.05 pi tal records: age at the time of sterilization, waiting time from the application to operation, and whether another operation was carried out simultaneously. Except in the case of five men who had undergone previous scrotal surgery, the vasectomies all were performed under local anesthesia in the outpatient department. The procedure, including postoperative observation, lasted about 90 minutes. A sperm test was recommended after 3 months and the sterilization was not to be relied on before azoospermia was confirmed. The female sterilizations were performed under general anesthesia, either by laparoscopy using the Falope Ring technique or by means of a minilaparotomy with resection of the tubes using Pommeroy's method. During the first 2 years of the study, the admissions were planned as a 2-night stay, with medical write-up and pre-anesthesia evaluation on the day of admission, and 1-night observation after the sterilization. During the last 3 years, the women were evaluated preoperatively as outpatients, sterilized on the day of admission, and discharged the same evening. If a patient wanted to stay longer, this was allowed. Abortion was induced concurrently with sterilization in 142 (26%) cases, but otherwise a dilation and curettage (D&C) was done routinely. The sterilized men and women were grouped according to the social classifications employed by the Institute for Social Research, Copenhagen. 2 The social classifications of the spouses were not taken into account in our study. The chi-square and Mann-Whitney rank sum tests were used for statistical evaluation. The level of statistical significance chosen wasp < RESULTS During the 5-year period, 1,457 sterilizations were performed, 832 (57%) in men and 625 (43%) in women, 427 (78%) by laparoscopy and 120 (22%) by laparotomy. Twenty-two men and 31 women were excluded from the study, as follows: 16 men and 21 women had emigrated, 5 men and 2 women were dead, 1 man and 3 women were mentally retarded, 3 women did not speak Danish, and 2 women had lodged complaints against the hospital. Consequently, 810 men and 594 women received a questionnaire, which was eventually returned by 709 men (88%) and 546 women (92%). The median observation time was 51 months (range, 20 to 98 months). As seen in Table 1, the men and women differed in severar respects. At the time the questionnaire was answered, 82 (12%) of the men and 117 (21 %) of the women had experienced a change in marital status. There were no differences in number of years spent in basic school. The women tended to be in a lower social class since 25% were grouped in the two lowest classes or had never been gainfully employed, whereas only 11% of the men were grouped in these classes. More women than men were unemployed at the time of the sterilization, 15% and 3%, respectively. More women than men gave health reasons for sterilization (Table 2). The health problems were not specified in the questionnaire, but according to the medical records, only a few women were steril- Table2 Reason for Wanting Sterilization a Men Women (n = 709) (n = 546) p Satisfied with no. of children <0.05 Problems with contraceptives <0.05 Against elective abortion <0.05 Lack of time for more children <0.05 Economic reasons <0.05 Marital problems <0.05 Health reasons <0.05 Other reasons NS a Often more than one reason per patient. 440 Kjersgaard et al. Male or female sterilization Fertility and Sterility

3 Table3 Former Contraceptive Use Among 1,255 Sterilized Men and Women and Their Partners Men Women (n = 709) (n = 546) Mean no. of contraceptives used before sterilization > Question not answered Contraceptive use just prior to sterilization Birth control pill Condom IUD Diaphragm Foam Nothing Question not answered Contraceptive failure One or more induced abortions ized on medical indications, including breast cancer, diabetes, and neurologic disease. Many women expressed fear of the possible long-term health effects of birth -control pills. It was noteworthy that more women than men gave marital problems as the reason for sterilization. The number of different contraceptives used before sterilization was remarkably similar in men and women (Table 3). Postoperative Side Effects One hundred twenty-eight men (18%) complained of minor discomfort and/or pain during or immediately after the operation, but only 48 (7%) returned to the hospital. The majority of these did not require surgical intervention, but 2 were admitted for evacuation of a hematoma. Because of persisting pain, 1 man later regretted the vasectomy. Twenty-two men (3%) experienced a deterioration in the quality of their sexual lives after the sterilization, 284 ( 40%) found that their sexual lives had improved, and 403 (57%) found that it was unchanged. One hundred thirty-eight women (25%) complained of minor discomfort and/or pain during or immediately after the operation, and 38 (7%) had minor complications, e.g., minor hemorrhage dur- ing the laparoscopy or a minor complication following the accompanying D & C or abortion. Major complications, such as bleeding requiring intervention and/or postoperative infections, were experienced by 7 women (1 %). Sixty-three women (12%) registered changes postoperatively in the menstrual pattern, and 53 (10%) experienced pelvic pain. Altogether, 116 (21%) women had menstrual changes and/or pelvic pain. Thirteen women (2%) experienced a deterioration in the quality of sexual life after sterilization, 197 (36%) said it had improved, and 336 (62%) that it was unchanged. During the last 3 years of the study, 300 laparoscopic sterilizations were performed (mini-laparotomies have been excluded). Two hundred seventeen (72%) were discharged after a 1-day admission, and 68 (23%) requested overnight stays because of abdominal pain or discomfort secondary to the anesthesia. The mortality rate in this material was 0. Four of the vasectomized men caused pregnancies 1 to 4 months after the sterilization, and eight women became pregnant 1 to 9 months postoperatively (1 ofthese pregnancies was ectopic). Elective abortion and resterilization were carried out in all cases. Three men were resterilized because the postoperative histologic examination failed to show the vas deferens. Regret was expressed by 19 men (3%) and 28 women (5%) (Table 4). This difference was significant (P < 0.05). The reason for the regret was mainly a wish for more children. Reversal of sterilization was requested by 10 men (53%) and 7 women (25%). Both men and women complained about the preoperative information given. Insufficient information about possible side effects of the sterilization was the major complaint (30%). Table4 Main Reasons for Regret (n = 4 7) Men Women (n = 19) (n = 28) The wish for more children Not feeling like a man/woman Postoperative pains Declining potency Failure of sterilization 2 7 Bleeding disturbances 3 11 No explanation given Kjersgaard et al. Male or female sterilization 441

4 Estimated Costs Since the patients do not pay for treatment at this hospital, the costs of male and female sterilization are not exactly known. However, the price of a 24-hour stay in the hospital is roughly 240 U.S. dollars. The average cost of an outpatient treatment is 60 U.S. dollars. The estimated cost of a male sterilization was 60 U.S. dollars, and 240 U.S. dollars for a female sterilization. DISCUSSION There was widespread satisfaction with the sterilization procedures by the men (97%) and the women (95%). Some differences between the men and women who were sterilized were recognized. The vasectomized men were characterized by peing older at sterilization than the women. In fact, 10% of the sterilized men were above 45 years old, reflecting the age-independent need for contraception among men. Almost all of the men lived in stable relationships, and their main reason for choosing sterilization was satisfaction with the number of children. They belonged to the upper social classes and, as reported previously, 3 many had already shown an interest in taking responsibility in birth control, since twice as many (43%) vasectomized couples used condoms just before the sterilization. Contraceptive failures had occurred among one-fifth of the vasectomized couples. Although a majority of the sterilized women lived in stable relationships, 16% were single parents at the time of sterilization. The sterilized women had more often experienced contraceptive side effects and failures (almost one-third of the women), often ending with induced abortions. These findings are in agreement with those of Alder et al., 3 who compared sterilized women with the wives of vasectomized men. Practically all of the men went through an uneventful outpatient vasectomy with few postoperative symptoms. Vasectomy failure was an exception, and was probably mainly due to lack of use of contraceptives until azoospermia was confirmed. Regret was rare. Based on animal studies, it has been claimed that vasectomy increases the prevalence of arteriosclerotic cardiovascular diseases. 4 Until now, no series based on human studies has been able to confirm this hypothesis. 5 Thirty percent to 50% of vasectomized men develop sperm antibodies in their blood, 6 and this has elicited concern regarding a possible development of immunologic diseases in vasectomized men. However, the only immunologic health effect identified is that sperm antibodies have a negative effect on the fertility of men undergoing reversal of sterilization. 6-8 In contrast to vasectomy, female sterilization was a more complicated surgical intervention, requiring general anesthesia. Although ideally, 1-day admission was planned, only 70% of the laparoscopically sterilized women chose to be discharged the same day. No major complications from the general anesthesia were observed, but many patients complained of minor secondary effects such as general malaise, vomiting, or fatigue, and consequently wanted to stay hospitalized 1 or 2 more days. Although the complication rate after female sterilization was low, as has been previously reported, 1 it must be remembered that the operation is an elective procedure performed on healthy women. The eight unwanted pregnancies due to sterilization failure all ended in elective abortions, thus requiring a second procedure under general anesthesia. One of the pregnancies was ectopic, which is a potentially lethal complication. It has previously been pointed out that there is an increased incidence of ectopic pregnancy when the conception occurs after tuballigation. 9 Almost one-fourth of the women felt that they had long-term sequelae to the sterilization such as menstrual changes and pelvic pain, although these complications were rarely considered so serious that the sterilization was regretted. It has been claimed that tubal ligation and the following impairment of the ovarian blood supply leads to menstrual disturbances. 10 In our review, 12% of the women experienced changes in the menstrual pattern, but as the data collection was retrospective, a risk of recall bias exists. Most reviews conclude that the observed menstrual changes are explained by the woman's age, former use of contraceptives, and sequelae of former gynecologic diseases, together with a raised consciousness for these problems. The findings that sexual dysfunction after sterilization was reported by only a few of the sterilized men and women, and that an unchanged or improved sexual life was reported by the majority, were in accordance with previous studies Smith et al., 1 in their review of comparative risks and costs of male versus female sterilization, estimated that the latter was twice as expensive as va- 442 Kjersgaard et al. Male or female sterilization Fertility and Sterility

5 sectomy. Our cost estimate showed that, ideally, female sterilization was approximately four times as expensive. The present study suggests that, in many respects, vasectomy is to be preferred to female sterilization whenever a couple seeks a permanent solution to fertility control. The responsibility for birth control traditionally rests with the woman, since she bears the physical and psychological burden of an unplanned pregnancy, and this is probably the.reason why women are motivated to undergo tubal ligation even though vasectomy is an easier procedure. The main question is how to motivate the men to be vasectomized instead of letting their wifes become sterilized. Alder et al. 3 pointed out that the approach to decision-making was quite different among couples who elected vasectomy and couples in which the woman was sterilized. Whereas the vasectomy couples were encouraged to consider the various alternatives together, the women undergoing sterilization were seldom interviewed with their husbands before the procedure, and the level of discussion about their decision generally was low. A multitude of factors are involved in the choice of sterilization procedure, and it is essential that both the husband and the wife are involved in the preoperative guidance and decision process, when risks and benefits of both procedures can be discussed and a more informed decision made. Acknowledgment. We thank Professor Ole Aalund, D.V.M., D.V.Sc., Professor of Preventive Medicine, Royal Veterinary Agricultural University, Frederiksberg, Denmark, for assistance in data processing. REFERENCES 1. Smith GL, Taylor GP, Smith KF: Comparative risks and costs of male and female sterilization. Am J Public Health 75:370, Enevoldsen B, Michelsen N, Friis-Rasche E, Kamper-J0rgensen F: Social Classifications. Ugeskr Laeger 142:544, Alder E, Cook A, Gray J, Tyrer L, Warner P, Bancroft J: The effects of sterization. A comparison of sterilized women with the wives of vasectomised men. Contraception 23:45, Clarcson TB, Alexander NJ: Longterm vasectomy effects on the occurrence of atherosclerosis in the rhesus monkeys. J Clin Invest 65:15, Goldacre MJ, Holford TR, Vessey MP: Cardiovascular disease and vasectomy. N Engl J Med 308:805, Linnet L, Hjort T, Fogh-Andersen P: Association between failure to impregnate after vasovasostomy and sperm agglutinins in semen. Lancet 1:117, Linnet L: Clinical immunology of vasectomy and vasovasostomy. Urology 22:101, Perrin EB, Woods JS, Namekata T, Yagi J, Bruce RA, Hofer V: Lonli;term effects of vasectomy on coronary heart disease. Am J Public Health 74:18, McCausland A: High rate of ectopic pregnancy, incidences and etiology. Am J Obstet Gynecol136:97, DeStefano F, Perlman JA, Peterson HB, Diamond EL: Long-term risk of menstrual disturbances after tubal sterilization. Am J Obstet Gynecol152:835, Foulkes J, Chamberlain G: Effects of sterilization on menstruation. South Med J 78:544, Rubinstein L, Benjamin L, Kleinkopf V: Menstrual patterns and women's attitudes following sterilization by Falope Rings. Fertil Steril31:641, Cox ML, Crozier IM: Female sterilisation: Longterm follow-up with particular reference to regret. J Reprod Fertil 35:624, Staff of The Margaret Pyke Centre: One thousand vasectomies. Br Med J 4:216, 1973 Kjersgaard et al. Male or female sterilization 443