Restoring fertility after tubal ligation in women 40 years of age and older: How do we counsel our patients?
Volume 113, Issue 4, Pages 733–734
William D. Schlaff, M.D.
Obstetrician-gynecologists, and reproductive endocrinologists in particular, know well that permanent sterilization in the form of tubal ligation is not anywhere near as permanent for many patients as we had anticipated. We are all well aware of data describing both the likelihood and the risk factors for women eventually regretting their decision to undergo tubal ligation. Age at the time of the procedure, in particular, as well as a new partner and desire for additional children are the most common reasons for up to 26% of women regretting their decision for sterilization (1). Additional risk factors for regret include unmarried status, recently postpartum at the time of surgery, nonwhite race, and lower levels of formal education (2). What may be underappreciated is the potential scope of the issue. For decades, the National Survey of Family Growth has provided comprehensive information about reproduction and contraception, among other important family-related statistics. The 2015–2017 data clearly show a decrease in the use of female sterilization with a concomitant increase in the use of long-acting reversible methods (3). Nevertheless, we should note this recent survey reported that 39.4% of all women in the United States aged 40–49 years used female surgical sterilization as their contraceptive method (notably, about one-third had undergone hysterectomy rather than tubal ligation) (3, 4). Given that 73.7% of the total number of women aged 40–49 years were using some type of contraception, we must conclude that more than 50% of women in this age group who reported using contraception had undergone surgical sterilization. This huge pool of women means that even a small percentage who regret their decision for tubal ligation would represent a potentially large group of patients for us to counsel. Indeed, a comprehensive survey of women who had undergone tubal sterilization reported that the 14-year cumulative probability of requesting information about reversal was 14.3% (2). The rate for women who had their sterilizing procedure when they were 18–24 years of age was 40.4%, almost four times higher than that observed in women who were over the age of 30 years at the time of their sterilization. The authors reported that the overall cumulative probability of actually obtaining a reversal was 1.1% (2). The goal of this “Fertile Battle” is to have our combatants help us decide how we should counsel the many women over the age of 40 years who regret their tubal ligation and want to have more children.