Intrauterine contraception just as effective as tubal ligation, safer
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.
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.
Perspective
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Patients need to balance many considerations when choosing a method of contraception. I applaud the authors for including patients in the design of the study. I find in my own practice that patients may confuse effectiveness and permanence — assuming that because tubal ligations are permanent, they must also be more effective. However, in adjusted analyses, this study showed that pregnancy rates within 1 year were actually lowest with levonorgestrel IUC, a reversible method. Pregnancy rates were equivalent between copper IUC and laparoscopic tubal ligation. Although low in all three groups, these failure rates were higher than earlier published estimates. This may be due to the young age of the population studied, the inherent limitations of retrospective big data or other methodologic variation from prior studies.
Complication rates were significantly higher in the tubal ligation group. The patients in this group were also older and more obese. There may be some underlying selection biases that aren’t apparent with this study design. But this is also important information for counseling patients as they decide on which contraceptive method to pursue. If failure rates are essentially equivalent, it may be preferable to avoid a procedure with higher rates of complications.
Finally, it is important to consider the complexity of the insurance barriers that patients with Medicaid face when accessing desired contraception. These patients must sign an MA31 form 30 to 180 days prior to obtaining a tubal ligation. No such paperwork or time limitations apply to IUCs. However, the costs of IUC removal and reinsertion may be prohibitive for patients that do not have consistent access to insurance.
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