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Contraception UPDATE

Long-Acting Reversible Contraception: An Option for Women Considering Sterilization

J. Joseph Speidel, MD, MPH; Barbara Clark, RN, MSN, MPH

Long-acting reversible contraception (LARC)—in the form of implants and intrauterine contraception (IUC)—has efficacy rates comparable to female sterilization.1 Yet in 2002, the most common methods of contraception used in the United States were oral contraceptives (19%), female sterilization (17%), and the male condom (11%).2 Only 2.1% of US women use LARC, and its use is similarly low in the United Kingdom (UK).2-4 In fact, in 2005 the National Institute of Clinical Health and Excellence (NICE) in the UK issued national guidelines on LARC with the expectation that increased use could reduce rates of unintended pregnancy.5 Although NICE includes injectables and the vaginal ring as LARC because they require administration less than once per cycle or month, they are less effective and have lower continuation rates than IUC or implants—the methods considered as LARC in the United States (Table).

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TABLE. Long-Acting Reversible Contraceptives Available in the United States

In many parts of the world, the use of LARC, particularly IUC, is higher than in the United States (Figure).6,7 For example, in Sweden, 21% of women report IUC as their contraceptive method.7 Countries with higher use of IUC often have lower levels of sterilizations, as in Sweden, where fewer than 4% of women are sterilized 8,9

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FIGURE. The percentages of IUC use by married women of reproductive age are shown.6,7 Population Reference Bureau, 2002 & 2008 data.

Women considering sterilization should also receive counseling on LARC as an alternative. Though most women do not regret choosing sterilization, the minority who do must either live with the decision or undergo time-consuming, expensive reversal procedures or in vitro fertilization, neither of which is certain to be effective.

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USE OF FEMALE STERILIZATION

In the United States, use of female sterilization varies with education, parity, race, and economic status.2 In 2002, 38% of women with a high school diploma or GED were sterilized, compared with only 8% of women with a minimum of a bachelor’s degree.2 Sterilization increases from 1% of women with zero births to 45% with 3 or more.2 Black women are more likely to choose sterilization than white women after controlling for socioeconomic and other confounders.10

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STERILIZATION REGRET

Young women are more likely to regret undergoing sterilization than older women. A recent systematic review found that women aged 30 or younger were 3.5 to 18 times more likely to request information about reversing sterilization and about 8 times more likely to undergo reversal or an evaluation for in vitro fertilization compared with women older than 30.11 Among women older than 30 years, black women are significantly more likely to desire sterilization reversal than white women.12

Other factors associated with regret include unpredictable life events such as a change in marital status or death of a child1; pressure by a clinician, spouse, relatives, or others; sterilization immediately after pregnancy; and childlessness.13,14

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AWARENESS OF LARC

Awareness of LARC is especially low in the United States. A study of 190 women aged 14 to 25 presenting for prenatal or abortion care found that only 50% had heard of IUC, 71% were uncertain about its safety, and 58% were unaware of its efficacy.15 Lack of information and misinformation about LARC among contraceptive providers, as well as high up-front costs for LARC, also limit its use in the United States.16

With proper counseling, a substantial number of women will select LARC in lieu of sterilization. In a recent survey in the UK, one-third of women considering permanent contraception chose a reversible method, most commonly IUC, citing its reversibility, non-contraceptive benefits, and avoidance of surgery as reasons for their choice.17

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CONCLUSION

LARC is an excellent but underused contraceptive choice for women who desire a reversible method that requires no daily effort. It is especially suitable for those considering sterilization, but who are uncertain about that option or are younger than age 30. By educating women about LARC and discussing their preferences and personal circumstances, health care professionals can help their patients choose the most suitable contraceptive.

For More Information

Association of Reproductive Health Professionals’ (ARHP) Visiting Faculty Programs on IUC and implants. Program activities include a PowerPoint slide module with talking points, an issue of ARHP’s accredited monograph, Clinical Proceedings, and patient education materials. A Clinical Update on Intrauterine Contraception www.arhp.org/Professional-Education/Programs/IUC-Update New Developments in Contraception: A Single-Rod Implant www.arhp.org/professional-education/programs/single-rod What You Need to Know: Labeling Changes for Depot medroxyprogesterone acetate www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/DMPA Grimes DA, Mishell DR Jr. Intrauterine contraception as an alternative to interval tubal sterilization. Contraception. 2008;77(1):6-9

The authors report no actual or potential conflicts of interest in relation to this article.

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J. Joseph Speidel, MD, MPH, is Adjunct Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco School of Medicine; and Director for Communication, Development and External Relations, Bixby Center for Global Reproductive Health, San Francisco, CA. Barbara Clark, RN, MSN, MPH, is a freelance writer in Arlington, VA.

References

1. Trussell J. Contraceptive efficacy. In Hatcher RA, Trussell J, Cates W Jr, Stewart FH, Kowal D. Contraceptive Technology: Nineteenth Revised Edition. New York, NY: Ardent Media, 2007.
2. Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 23. 2005;25:1-160.
3. Mosher WD, Martinez G, Chandra A, Abma J, Willson S. Use of Contraception and Use of Family Planning Services in the United States, 1982-2002: A Fact Sheet for Advance Data No. 350. National Center for Health Statistics, Hyattsville, MD:2004. www.cdc.gov/nchs/data/ad/ad350.pdf. Accessed October 14, 2008.
4. Wellings K, Zhihong Z, Krentel A, et al. Attitudes towards long-acting reversible methods of contraception in general practice in the UK. Contraception. 2007;76(3): 208-214.
5. National Institute for Health and Clinical Excellence. Long-acting reversible contraception. Clinical Guideline. Issued October 26, 2005. www.nice.org.uk/ guidance/index.jsp?action=byId&o=10974. Accessed October 14, 2008.
6. Clifton D, Kaneda T, Ashford L. Family Planning Worldwide 2008 Data Sheet Washington, DC: Population Reference Bureau. 2008. www.prb.org/pdf08/08WPDS_Eng.pdf. Accessed October 14, 2008.
7. Sonfield A. Popularity Disparity: Attitudes about the IUD in Europe and the United States, Guttmacher Policy Review, Fall 2007, Volume 10, Number 4. www.guttmacher.org/pubs/gpr/10/4/gpr100419.pdf. Accessed October 14, 2008.
8. Inki P. Long-term use of the levonorgestrel-releasing intrauterine system. Contraception. 2006;75(6):S161-S166.
9. Oddens BJ, Milsom I. Contraceptive practice and attitudes in Sweden 1994. Acta Obstet Gynecol Scand. 1996;75(10): 932-940.
10. Borrero S., Schwarz, B., Reeves MF, Bost JE, Creinin M, Ibrahim SA. Race, insurance status, and tubal sterilization. Obstet Gynecol. 2007;109(1):94-100.
11. Curtis KM, Mohllajee AP, Peterson HB. Regret following female sterilization at a young age: a systematic review. Contraception. 2006;73(2):205-210.
12. Borrero SB, Reeves MF, Schwarz EB, Bost JE, Crenin MD, Ibrahim SA. Race, insurance status, and desire for tubal sterilization reversal. Fertil Steril. 2008;90(2): 272-277.
13. Pati S, Cullins V. Female sterilization. Evidence. Obstet Gynecol Clin North Am. 2000;27(4):859-899.
14. Royal College of Obstetricians and Gynecologists. Male and female sterilisation. Evidence-based clinical guideline number 4. London: RCOG Press, 2004. www.rcog.org.uk/resources/Public/pdf/sterilisation_full060607.pdf. Accessed October 14, 2008.
15. Stanwood NL, Bradley KA. Young pregnant women’s knowledge of modern intrauterine devices. Obstet Gynecol. 2006;108(6):1417-1422.
16. Speidel JJ, Harper, CC, Shields WC. The potential of long-acting reversible contraception (LARC) to decrease unintended pregnancy. Contraception. 2008; 78(3); 197-200.
17. Mattinson A, Mansour D. Female sterilisation: is it what women really want? J Fam Plann Reprod Health Care. 2003;29(3);136-139.

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