What is Permanent Contraception?

Reproductive age women can be classified according to intention for future fertility; certain desire for future pregnancy, unsure of desire for future pregnancy, and certain desire to never become pregnant again [1]. For women certain of the desire to never become pregnant, the term “family completer” also applies.  Permanent methods of contraception make sense for women who have completed family size regardless of number of children. Although long acting reversible methods of contraception (IUDs, implants) offer a highly effective alternative to permanent methods, many women reasonably object to side-effect profiles of these methods, the need for periodic replacement or health checks associated with their use, or with the physical presence of a device.

Many medical and lay sources use the antiquated terminology “sterilization” to refer to contraception methods that block or remove the fallopian tubes in women or vas deferens in men.  However, this term is technically inaccurate as women with a functioning uterus can conceive through assisted reproductive technology.   Medically, the term sterility implies undesired infertility.  Thus, the term “sterilization” suggests an involuntary or coercive action.  Indeed, “sterilization” is associated with a history of deplorable campaigns of eugenics carried out in many countries, including the United States.

There is no question involuntary family planning of any type is an unacceptable violation of human rights. However, denying a woman access to desired reversible or permanent contraception can lead to unintended pregnancy, a condition that frequently results in abortion, or unwanted birth [2]. We have proposed the term “permanent contraception” as an alternative, as this implies an active and informed choice; the same decision-making process as reversible contraception [3].

The need for new methods of Permanent Contraception

Globally, permanent contraception represents the leading method of family planning for women, particular for those over age 35 [4]. Concerns about reversibility and side effects limit access and use of permanent methods in some more developed countries, while inadequate availability of surgical facilities and trained personnel presents a significant barrier to use in many developing nations.  The United Nations Population Division projects that world population will increase from the current 7.7 billion to 11 billion by 2100 [5].  This estimate anticipates that over the next several decades each woman will have, on average, only two children. Of course, some will have fewer and others more, but the balance will reflect a total fertility rate of 2.1.  An estimated 220 million women worldwide lack access to modern methods of contraception [6].  In many regions with high unmet need, women marry and achieve their desired family size at an early age [7-9].  In South Asia, women express a preference for permanent methods [7, 9]. 

What is Nonsurgical Permanent Contraception, and how could it address unmet need?

The only currently available approaches to permanent contraception for both men and women involve surgical procedures [10].  For women, this requires an incision into the abdominal (peritoneal) cavity followed by either placement of an obstructing clip or band, or removal of a portion (partial salpingectomy) or the entire (salpingectomy) fallopian tube.  In the immediate postpartum period, surgeons typically perform the procedure through a small incision below the umbilicus following vaginal delivery, or at the time of cesarean section.  At other times, the most common approach involves laparoscopy.  All surgical approaches require some type of anesthesia, specialized facilities, and trained surgeons.   In many regions, these requirements limit access to and acceptability of the procedures.  Where laparoscopy equipment is not available, even interval procedures are done by laparotomy. Although hysteroscopic approaches to permanent contraception have been introduced, none are currently marketed.  Hysteroscopy, a surgical procedure that involves passing a small scope through the cervix into the uterine cavity, provides an option that does not enter the body cavity, but still requires surgical facilities, equipment and training.

Nonsurgical permanent contraception (NSPC) refers to approaches that block the fallopian tubes without a surgical procedure [1].  A nonsurgical approach could greatly increase access, as surgical facilities and training would not be required.  Nonsurgical approaches in development are appropriate for use by midlevel clinicians.  Eliminating the use of surgery and need for anesthesia should increase safety and lower costs. 

The idea for nonsurgical permanent contraception for women is not new. In the 70s and 80s, several groups devoted considerable research effort to this area [11, 12]. One method, quinacrine sterilization (QS), was introduced in several developing nations prior to sufficient testing of safety and efficacy or regulatory approval in the US or Europe [13].  The absence of strong regulatory approval and broad acceptance of the approach in more-developed regions left QS vulnerable to criticism from both human rights advocates and policy makers opposed to contraception [14]. Although the extensive clinical data accumulated with QS strongly supports the safety of the approach, its efficacy, particularly among younger women, is unacceptably poor [15, 16]. While improving the efficacy of QS is possible, concerns about safety have hampered efforts to restart this research. 

Methods of contraception must be viewed as safe, voluntary, and non-coercive to become highly acceptable.   The enthusiasm for and promotion of methods for family planning that are not approved in the United States or European Union in developing countries leads to suspicion regarding the safety of methods and the goals and motives of international family planning programs.  Therefore, to be successfully adopted, a new method of permanent female contraception must follow a careful path toward concurrent regulatory approval in both lesser- and more-developed nations. 

Citations

1.           Jensen, J.T., Nonsurgical permanent contraception for women: let’s complete the job. Contraception, 2015. 92(2): p. 89-90.

2.           Finer, L.B. and M.R. Zolna, Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception, 2011. 84(5): p. 478-485.

3.           Jensen, J.T., Permanent contraception: modern approaches justify a new name. Contraception, 2014. 89(6): p. 493-4.

4.           World Contraceptive Use. 2021  [cited 2021 January 5, 2021]; Available from: https://www.un.org/development/desa/pd/data/world-contraceptive-use.

5.           United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Volume I: Comprehensive Tables (available at  https://population.un.org/wpp/Publications/Files/WPP2019_Volume-I_Comprehensive-Tables.pdf).

6.           Darroch, J.E. and S. Singh, Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys. Lancet, 2013. 381(9879): p. 1756-62.

7.           Chatterjee, S., Rural-urban differentials in fertility levels and fertility preferences in West Bengal, India: a district-level analysis. J Biosoc Sci, 2020. 52(1): p. 117-131.

8.           Ariho, P. and A. Kabagenyi, Age at first marriage, age at first sex, family size preferences, contraception and change in fertility among women in Uganda: analysis of the 2006-2016 period. BMC Womens Health, 2020. 20(1): p. 8.

9.           Thulaseedharan, J.V., Contraceptive use and preferences of young married women in Kerala, India. Open Access J Contracept, 2018. 9: p. 1-10.

10.         Alton, K. and J. Jensen, Update on Permanent Contraception for Women. Current Obstetrics and Gynecology Reports, 2018. 7(4): p. 163-171.

11.         Sciarra, J.J., W. Droegemueller, and J.J. Speidel, Advances in female sterilization techniques: proceedings of a Workshop on Advances in Female Sterilization Techniques, held in Minneapolis, Minnesota, United States of America, ed. N.U.P.f.A.R.o.F. Regulation. 1976: Medical Dept., Harper & Row.

12.         Zatuchni, G.I., et al., eds. Female Transcervical Sterilization: Proceedings of an lnternational Workshop on Non-Surgical Methods for Female Tubal Occlusion June 22 to 24, 1982, Chicago, Illinois. Program for Applied Research on Fertility Regulation. 1983, Harper & Row.

13.         Hieu, D.T., et al., The acceptability, efficacy and safety of quinacrine non-surgical sterilization (QS), tubectomy and vasectomy in 5 provinces in the Red River Delta, Vietnam: a follow-up of 15,190 cases. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 2003. 83 Suppl 2: p. S77-85.

14.         Bhattacharyya, S., Quinacrine sterilization (QS): the ethical issues. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics, 2003. 83 Suppl 2: p. S13-21.

15.         Sokal, D.C., et al., Contraceptive effectiveness of two insertions of quinacrine: results from 10-year follow-up in Vietnam. Contraception, 2008. 78(1): p. 61-5.

16.         Sokal, D.C., et al., Safety of quinacrine contraceptive pellets: results from 10-year follow-up in Vietnam. Contraception, 2008. 78(1): p. 66-72.