Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation

/

Eleanor Bimla Schwarz MD, MS, Carrie A. Lewis MPH, Melanie S. Dove ScD, Eryn Murphy MS, Diana Zuckerman PhD, Claudia Nunez-Eddy MS, Daniel J. Tancredi PhD, Raegan McDonald-Mosley MD, MPH, Sarita Sonalkar MD, MPH, Mark Hathaway MD, MPH & Aileen M. Gariepy MD, MPH 

Journal of General Internal Medicine

February 23, 2022

….Tubal ligation remains common in the USA, particularly among low-income individuals7 and those with chronic medical conditions such as diabetes.8 Compared to privately insured individuals, US patients with public insurance more frequently report a desire for reversal of tubal sterilization.9 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. To inform such contraceptive counseling, we estimated the real-world effectiveness and safety of placement of a levonorgestrel or copper intrauterine contraceptive (IUC) as compared to laparoscopic tubal ligation among a large and diverse cohort of individuals receiving publicly funded healthcare in California….

Key Results

We identified 35,705 patients who had a levonorgestrel IUC placed, 23,628 patients who had a copper IUC placed, and 23,965 patients who underwent laparoscopic tubal ligation. In unadjusted analyses, rates of pregnancy within 1 year were similar following levonorgestrel IUC (2.40%) or copper IUC placement (2.99%) or tubal ligation (2.64%). In adjusted analyses, compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUC (adj IRR 0.72, 95% CI 0.64–0.82) and similar with placement of a copper IUC (adj IRR 0.92, 95% CI 0.82–1.05). Procedural complications such as infection (0.35% vs. 2.91%) were significantly less common with IUC placement than tubal ligation. Claims for pelvic and abdominal pain decreased in frequency with time since all procedures; 6 to 12 months post-procedure, pelvic pain claims were less common after levonorgestrel IUC (adj IRR 0.69, 95% CI 0.65–0.73) or copper IUC placement (adj IRR 0.70, 95% CI 0.66–0.75) than tubal ligation.

Conclusions

IUC appears at least as effective as laparoscopic tubal ligation at 1-year post-procedure with lower rates of infection and pelvic pain 6 to 12 months post-procedure.

REFERENCES

  1. Dehlendorf C, Levy K, Kelley A, Grumbach K, Steinauer J. Women’s preferences for contraceptive counseling and decision making. Contraception 2013;88:250-6.

  2. Anderson S, Frerichs L, Kaysin A, Wheeler SB, Halpern CT, Lich KH. Effects of Two Educational Posters on Contraceptive Knowledge and Intentions: A Randomized Controlled Trial. Obstet Gynecol 2019;133:53-62.

  3. Eisenberg DL, Secura GM, Madden TE, Allsworth JE, Zhao Q, Peipert JF. Knowledge of contraceptive effectiveness. Am J Obstet Gynecol 2012;206:479 e1-9.

  4. Werner CA, Papic MJ, Ferris LK, Schwarz EB. Promoting safe use of isotretinoin by increasing contraceptive knowledge. JAMA Dermatol 2015;151:389-93.

  5. Sundaram A, Vaughan B, Kost K, et al. Contraceptive Failure in the United States: Estimates from the 2006-2010 National Survey of Family Growth. Perspect Sex Reprod Health 2017;49:7-16.

  6. Kramer DB, Xu S, Kesselheim AS. How does medical device regulation perform in the United States and the European union? A systematic review. PLoS Med 2012;9:e1001276

  7. Beshar I, So J, Chelvakumar M, Cahill EP, Shaw KA, Shaw JG. Socioeconomic differences persist in use of permanent vs long-acting reversible contraception: An analysis of the National Survey of Family Growth, 2006 to 2010 vs 2015 to 2017. Contraception 2021;103:246-54.

  8. Schwarz EB, Postlethwaite D, Hung YY, Lantzman E, Armstrong MA, Horberg MA. Provision of contraceptive services to women with diabetes mellitus. J Gen Intern Med 2012;27:196-201.

  9. Borrero SB, Reeves MF, Schwarz EB, Bost JE, Creinin MD, Ibrahim SA. Race, insurance status, and desire for tubal sterilization reversal. Fertil Steril 2008;90:272-7.

  10. Laird N, Olivier D. Covariance Analysis of Censored Survival Data Using Log-Linear Analysis Techniques. Journal of the American Statistical Association 1981;76:231-40.

  11. Heinemann K, Reed S, Moehner S, Minh TD. Comparative contraceptive effectiveness of levonorgestrel-releasing and copper intrauterine devices: the European Active Surveillance Study for Intrauterine Devices. Contraception 2015;91:280-3.

  12. Peterson HB, Xia Z, Hughes JM, Wilcox LS, Tylor LR, Trussell J. The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Am J Obstet Gynecol 1996;174:1161-8; discussion 8-70.

  13. Eeckhaut MCW, Sweeney MM, Feng L. Desire for Sterilization Reversal Among U.S. Females: Increasing Inequalities by Educational Level. Perspect Sex Reprod Health 2018;50:139-45.