Written by Eleanor Bimla Schwarz, MD, MS and Kelly M. Treder, MD, MPH

Since the Dobbs decision, as access to abortion services has become more challenging in many parts of the country, the possibility of contraceptive failure has become more distressing. Unintended pregnancy is relatively common, even among patients who use contraception.¹ Because many patients and clinicians remain under the misperception that permanent birth control (e.g., tubal ligation or salpingectomy) is the most effective way for people to prevent pregnancy, a growing number of people in the US have been undergoing tubal sterilization surgeries.²

However, in a recent analysis of multiple waves of representative data from the National Survey of Family Growth³ real-world tubal sterilization failure rates ranged from 2.9% to 5.2%, suggesting that these surgeries are far less effective than many have believed.⁴ An analysis of California Medicaid data found similar rates of failure after hysteroscopic and laparoscopic tubal sterilization. There were approximately 2.61 pregnancies after laparoscopic tubal sterilization per hundred-woman years of observation.⁵ This means that intrauterine contraceptives, which can be used for up to 12 years, are at least as effective as tubal surgery, and may be more effective if an IUD is used.⁶ The subdermal implant which can be safely used for 5 years, is typically even more effective and is likely the most effective contraceptive method available.⁷ Pelvic pain, which is another important consideration for many patients, is less common with the use of a contraceptive implant or IUD placement than after tubal surgery.⁶ Vasectomy is also typically safer, more effective, and more easily reversed than tubal sterilization.⁸

There is a critical need to ensure patients receive evidence-based information prior to irreversible contraceptive surgeries. While there are many factors to consider when identifying which contraceptive method will best meet a patient’s personal needs, for those seeking information on the comparative effectiveness of available contraceptives we need to communicate that the implant, vasectomy, and the IUD are all more effective than tubal surgery with fewer complications.

RHAP Resources:

Your Birth Control Choices Fact Sheet

Permanent Birth Control (Sterilization)

IUD Fact Sheet

Progestin Implant Fact Sheet

Sources:

1. O’Connor-Terry C, Zhao X, Mor MK, Chang JC, Callegari LS, Borrero S, Quinn DA. Abortion After Pregnancy Occurrence with Contraceptive Use Among Veterans. J Womens Health (Larchmt). 2024 Jul 1. doi: 10.1089/jwh.2023.0829. Epub ahead of print. PMID: 38946661.

2. Xu X, Chen L, Desai VB, Gross CP, Pollack CE, Schwartz PE, Wright JD. Tubal Sterilization Rates by State Abortion Laws After the Dobbs Decision. JAMA. 2024 Sep 11. PMID: 39259564

3. Schwarz EB, Chiang AY, Lewis CA, Gariepy AM, Reeves MF. Pregnancy after Tubal Sterilization in the United States, 2002 to 2015. NEJM Evid. 2024. doi: 10.1056/EVIDoa2400023.

4. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. Am J Obstet Gynecol. 1996 Apr;174(4):1161-8; discussion 1168-70. doi: 10.1016/s0002-9378(96)70658-0. PMID: 8623843.

5. Gariepy AM, Lewis C, Zuckerman D, et al. Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study. Fertil Steril. 2022;117(6):1322-1331. doi:10.1016/j.fertnstert.2022.03.001

6. Schwarz EB, Lewis CA, Dove MS, et al. Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation. J Gen Intern Med. 2022;37(16):4168-4175. doi:10.1007/s11606-022-07433-4

7. Reed S, Minh TD, Lange JA, Koro C, Heinemann K. Pregnancy and pregnancy outcomes in a prospective cohort study: Final results from the Nexplanon Observational Risk Assessment Study (NORA). Contraception. 2023 Apr;120:109920. doi: 10.1016/j.contraception.2022.109920. Epub 2022 Dec 15. PMID: 36529241.

8. Jamieson DJ, Costello C, Trussell J, et al. The risk of pregnancy after vasectomy [published correction appears in Obstet Gynecol. 2004 Jul;104(1):200]. Obstet Gynecol. 2004;103(5 Pt 1):848-850. doi:10.1097/01.AOG.0000123246.11511.e4

Pharma-free: The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or products. The information in the Insights is unbiased, based on science alone.

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