Document Type : Original Article
1 Department of Midwifery and Reproductive Health, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
2 Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
3 Department of Nursing, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
Permanent contraception method is a greatly desired
and frequently used contraceptive option for women
around the world who desire never to become pregnant
An increasing number of women have shown post-TL regret
for their decision to undergo TL. Some studies have
revealed that the prevalence of post-sterilization regret ranges
from 0.9% to 26% (
Some factors such as sterilization age, the death of children, the number of children at the time of TL, remarriage, changes in socioeconomic status, and lack of information about surgical sterilization contribute to post-sterilization regret (
Although TL is particularly common in the developing than in the developed countries, recently the majority of studies on post-sterilization regret have been carried out on women in the developed countries (
In this cross-sectional study, first, a pilot study was conducted on 20 women. Then, using the appropriate formula with α set at 0.05 and 1-β at 0.95, it was found that a sample size of 40 women was needed for each group. This cross-sectional study was conducted on women (aged 20-40 years) undergone TL. They were selected from a health care center in Guilan province (Iran) during 2015-2016.
Satisfaction with TL was evaluated in response to questions such as “Do you think TL as a permanent method of birth control was a good choice for you?” Those who answered 'no' were further asked: “Do you regret for deciding to undergo sterilization?” If the answer was a consistent yes, then this group was considered to have regretted the decision (women regretting sterilization group). Further questioning continued to seek reasons for regret. This included interrogation regarding menstrual irregularities, depression and anxiety, sexual dysfunction, and having desire to have more children. The last question was: “Have you ever requested that your sterilization is reversed?” Possible responses included “no” and “yes” (
A total of 238 women were enrolled in the study; 166 women were eligible for inclusion, and 72 women were excluded from the study. The final analysis was conducted on 41 women regretting the decision, and 125 women not regretting the decision.
The inclusion criteria were free of any gynecological diseases, free of chronic diseases, include diabetes, hypertension, thyroid and cardiovascular diseases, not being in the postmenopausal period, not using antidepressants, not having the history of sexual abuse, not having the history of menstrual disorders before TL, not being a cigarette smoker, not having the history of operative gynecology except caesarean section and TL, and not doing breastfeeding.
We compared the distribution of demographic and obstetrical characteristics, menstrual disorder, sexual function, and depression and anxiety between the two groups.
This study was performed after obtaining approval from our Institutional Review Board (IRB # 1056668). All women participated voluntarily and provided a signed informed consent.
Menorrhagia is defined as a Pictorial Blood Loss Assessment Chart (PBLAC) score of ≥100 (
The participants’ sexual function was evaluated and compared by using the Female Sexual Function Index (FSFI) questionnaire. This standardized questionnaire is a validated, 19 items, self-administered, and a screening tool that measures six aspects of sexual function (desire, arousal, lubrication, orgasm, satisfaction, and pain). Each question describes the status of sexual function during the last 4 weeks. The full-scale score range is from 2.0 to 36.0, with higher scores associated with a lesser degree of sexual dysfunction (
The Hospital Anxiety and Depression Scale (HADS) was used to assess depression and anxiety. The instrument has two subscales including anxiety (HADS-A) and depression (HADS-D). The HADS is a self-administered instrument consisting of 14 questions. The instrument has two subscales including anxiety (seven items) and depression (seven items). All items rate from 0 to 3. Sum scores <8 indicate normal range; scores 8-10 reflect mild alterations and scores ≥11 indicate clinical relevance of symptoms (
The study was approved by the Tarbiat Modares Ethical Committee and all subjects signed a written informed consent.
All statistical analyses were performed by the SPSS software (version 20.0, SPSS Inc., Chicago, IL, USA). Student’s t test and Chi-square test were used to reveal the statistical differences between the two groups, after adjusting for women’s age (at the time of data collection), age at the time of sterilization, partner’s age, education levels, BMI. We used logistic regression to determine the influencing factors associated with regretting sterilization. Women’s age (at the time of data collection), age at the time of sterilization, pre-sterilization counseling, PBLAC score, the number of days of bleeding days, the length of menstrual cycles, total score of FSFI, and total score of HADS were included in the regression analysis as continuous variables. Odds ratio (OR) at 95% confidence interval (CI) were also calculated for each factor. P<0.05 were considered to be statistically significant.
The mean duration of TL was 4.6 ± 1.2 years. The demographic and reproductive of participants are shown in Table 1. Both groups were not significantly different in terms of age (at the time of data collection), partner’s age, menarche age, BMI, parity, educational level, previous contraceptive use, and the method of delivery. There were significant differences in pre-sterilization counseling between the two groups. Of 166 women who completed the questionnaires, 34.9% did not receive any pre-sterilization counseling from a physician or a healthcare worker (
Regret declined as the age of the TL women increased. There was a significant difference between women with poststerilization regret and those who did not regret sterilization. Post TL regret was found in those aged less than 30 years (age at the time of sterilization) and those above the age of 30 (P=0.01,
Table 2 displays the findings regarding the participants' menstruation disorders. There was a significant difference between the two groups in PBLAC score for menstrual loss between the two groups. The mean score of PBLAC was significantly higher in the women with poststerilization regret compared to their counterparts who did not regret sterilization (214.21 ± 116.08 vs. 126.24 ± 72.46, P<0.001) (
Comparison of demographic and personal characteristics between two groups
|Parameter||Regret n=41||Non-regret n=125||P value|
|Mean ± SD||n (%)||Mean ± SD||n (%)|
|Women’s age (Y)||36.06 ± 3.20||35.95 ± 4.40||0.10**|
|Partner’s age (Y)||40.51 ± 4.84||41.21 ± 4.13||0.36**|
|Age of menarche (Y)||12.78 ± 1.72||12.64 ± 1.23||0.57**|
|Age of sterilization (Y)|
|≤30||19 (46.3)||30 (24)||0.01*|
|>30||22 (53.7)||95 (76)|
|Parity||2.36 ± 0.58||2.32 ± 0.56||0.65**|
|BMI (Kg/m2)||28.00 ± 5.92||27.96 ± 4.62||0.97**|
|Primary school||13 (31.7)||24 (19.2)|
|Completed high school||12 (29.3)||50 (40)||0.20*|
|University||16 (39)||51 (40.8)|
|Method of delivery|
|Normal vaginal delivery||10 (24.4)||31 (24.8)||0.12*|
|Caesarean section||31 (75.6)||94 (75.2)|
|Previous contraceptive method used|
|Pill||4 (9.8)||7 (5.6)|
|Condom||31 (75.6)||104 (83.2)||0.51*|
|Other***||6 (14.6)||14 (11.2)|
|No||35 (85.4)||23 (18.4)||<0.001*|
|Yes||6 (14.6)||102 (81.6)|
BMI; Body mass index, *; Chi-square test, **; t test, and ***; This category included withdrawal and natural family planning or the rhythm method.
Comparison of changes in menstrual function between two groups
|Parameter||Regret n=41||Non-regret n=125||OR adjusted(95% CI)||P value*|
|Mean ± SD||n (%)||Mean ± SD||n (%)|
|Menstrual cycle length (day)||25.34 ± 6.81||29.01 ± 5.94||0.89 (0.83-0.96)||0.005|
|Duration of bleeding menstrual (day)||7.41 ± 1.91||6.30 ± 1.35||1.64 (1.24-2.16)||<0.001|
|Menstrual irregularities||13 (31.7)||20 (16)||2.14 (0.91-5.05)||0.07|
|Menorrhagia||32 (78)||72 (57.6)||2.44 (1.04-5.69)||0.03|
|PBLAC score||214.21 ± 116.08||126.24 ± 72.46||1.01 (1.006-1.01)||<0.001|
BMI; Body mass index, OR; Odds ratio, CI; Confidence interval, and *; P values are adjusted for women’s age (at the time of data collection), age at the time of sterilization, education levels, BMI.
Evaluation of the two groups by FSFI showed that all mean values were lower in the women with poststerilization regret. The differences of scores in the two groups were statistically significant in the domains of orgasm (OR= 0.68, CI:0.49-0.94, P=0.02), satisfaction (OR=0.59, CI:0.41-0.84, P=0.004), pain (OR=0.72, CI:0.54-0.95, P=0.02), and total FSFI scores (OR=0.88, CI:0.88-0.96, P=0.007) (
The women regretting with poststerilization regret had more sexual dysfunction in the domains of satisfaction (48.8 vs. 30.4%, P=0.03), pain (48.8 vs. 28%, P=0.01), and total FSFI scores (63.4 vs. 40.8%; P=0.01) than the other group (data not shown).
The mean scores of anxiety and depression were found to be higher in the women with poststerilization regret compared to their counterparts who did not regret sterilization, and the differences between the two groups were statistically significant on anxiety scale (OR=1.14, CI:1.03-1.27, P= 0.01), depression scale (OR=1.14, CI:1.02-1.27, P=0.01), and total HADS scores (OR=1.09, CI:1.02-1.16, P= 0.01) (
Of the women regretting sterilization, 61% (n=25) demonstrated elevated HADS anxiety scores (i.e. HADS anxiety subscale ≥11), and 17.1% (n=7) showed higher HADS depression scores (i.e. HADS depression subscale ≥11). Finally, 35 women (85.4%) in the women regretting sterilization group scored above the cut-offs (≥11) for both anxiety and depression (data not shown).
The reason for requesting sterilization in the majority of women was the higher effectiveness of sterilization (36.8%) as compared to other methods. Other reasons were having enough children or having no desire for more children (35.5%), and unsatisfied with other contraceptive methods for their many side effects (27.7%).
Scores and total scores for the domain subgroups of sexual function and HADS between two groups
|Parameter||Regret n=41 (Mean ± SD)||Non-regret n=125 (Mean ± SD)||OR adjusted (95% CI)||P value*|
|Desire||2.83 ± 0.78||3.11 ± 0.76||0.66 (0.39-1.10)||0.11|
|Arousal||3.16 ± 1.04||3.49 ± 0.89||0.70 (0.45-1.07)||0.10|
|Lubrication||3.68 ± 1.28||4.06 ± 1.08||0.80 (0.56-1.14)||0.22|
|Orgasm||3.55 ± 1.42||4.17 ± 1.13||0.68 (0.49-0.94)||0.02|
|Satisfaction||3.82 ± 1.14||4.49 ± 1.13||0.59 (0.41-0.84)||0.004|
|Pain||3.81 ± 1.65||4.41 ± 1.19||0.72 (0.54-0.95)||0.02|
|Total score||20.87 ± 5.91||23.75 ± 4.52||0.88 (0.88-0.96)||0.007|
|Anxiety score||11.39 ± 4.06||9.48 ± 3.67||1.14 (1.03-1.27)||0.01|
|Depression score||7.97± 3.68||6.12 ± 3.49||1.14 (1.02-1.27)||0.01|
|Total score||18.97 ± 6.75||15.56 ± 6.07||1.09 (1.02-1.16)||0.01|
FSFI; Female Sexual Function Index, HADS; Hospital Anxiety and Depression Scale, BMI; Body mass index, OR; Odds ratio, CI; Confidence interval, and *; P values are adjusted for women’s age (at the time of data collection), age at the time of sterilization, education levels, BMI.
No significant difference was found between the women regretting sterilization and the women not regretting sterilization in reasons for requesting sterilization (data not shown).
When the women with poststerilization regret were asked to state reason(s) for regret, 43.9% (n=18) had both menorrhagia, anxiety and depression, 19.5% (n=8) reported having sexual problems, menorrhagia, and anxiety and depression after the operation, 14.6% (n=6) had anxiety and depression, 12.2% (n=5) simply wanted to have another child, and about 9.8% (n=4) regretted the operation because it brought about only menorrhagia.
Requesting ROS after TL was 3% (5 women). The reasons for requesting ROS after TL involve both menorrhagia, and anxiety and depression (n=2), both sexual problems and menorrhagia (n=1), desire for having more children (n=1), and only menorrhagia (n=1). Age at the time of sterilization can affect desire for ROS. Women younger than 30 years at the time of sterilization were more likely to request reversal than those who were above 30 years old (80 vs. 20%, P=0.02) (data not shown).
There were significant differences in pre-sterilization counseling between the women requested reversal and those who did not. Of the 5 ROS women, nobody did receive any pre-sterilization counseling from a physician or a healthcare worker (P=0.005) (data not shown).
Finally, in order to build a prediction model and to find the most important factors predicting with poststerilization regret, we used a logistic regression model in a backward manner. The results of fitting the logistic regression model to the data (
Logistic regression analysis of 166 women for regretting sterilization
|Parameter||OR (95% CI)||P value*|
|Age of sterilization (Y)|
|PBLAC score||1.01 (1.004-1.07)||0.001|
|Number of days of bleeding||1.37 (1.01-1.99)||0.04|
|Length of menstrual cycles||0.91 (0.83-0.99)||0.03|
OR; Odds Ratio, CI; Confidence interval, †; Reference category, *; P value logistic regression, and women’s age (at the time of data collection), age at the time of sterilization, parity, pre-sterilization counseling, PBLAC score, number of days of bleeding, length of menstrual cycles, total score of FSFI, and total score of HADS were included in the regression analysis as continuous variables. Only significant results are presented.
In the logistic regression model, age of sterilization (OR=2.67, CI: 1.91-7.81, P=0.04), pre-sterilization counseling (OR=19.91, CI: 6.62-59.90, P<0.001), score of PBLAC (OR=1.01, CI: 1.004-1.07, P=0.001), and the number of bleeding days (OR=1.37, CI: 1.01-1.99, P=0.04) were significantly associated with poststerilization regret. However, the length of menstrual cycles (OR=0.91, CI: 0.83-0.99, P=0.03) was negatively related to regretting sterilization regret (
Tubal ligation is chosen by the women who have decided to limit the size of their families or those who are sure that no longer want to have children (
The present results indicated that women with poststerilization regret were more likely to experience an increase in menorrhagia when compared with the other group. We found a significant increase in PBLAC score for menstrual blood loss in the women regretting sterilization when compared with the other group. Also the women regretting sterilization were more likely to experience a shortening of the duration of menses and an increase in the number of days with bleeding. The term “Post-TL Syndrome” (PTLS) has been used variously to include menstrual disorders, dysmenorrhea, premenstrual distress, and miscellaneous other conditions like menopausal syndrome, feeling of regret, and need for recanalization (
Our findings suggest that menorrhagia were more common in the women regretting sterilization in comparison to the women not regretting sterilization. The relationship between regretting sterilization and menstrual disorders is a complex process influenced by multiple factors including psychological and cultural conditions, as well as behavior, ethnicity, climate, and religion.
It was revealed that regret following TL may be an influencing factor of women’s sexual dysfunction. In the present study, the prevalence of FSD in the women regretting TL was 63.4% in comparison with 40.8% in the other group. Warehime et al. (
“Making a decision about sterilization is difficult for both women and men, as it means ending fertility. As negative biological and psychological issues may occur after vaginal surgeries including loss of sexual function, the same negative effects after TL could be expected”. The negative effects of PTLS on general health status and the sexual function have not been described yet (
The results of the present study showed that anxiety and depression were more common in the women regretting sterilization in comparison to the other group. Kelekçi et al. (
The psychological status of women prior to the sterilization technique may be important in predicting future satisfaction and success of an operation. Depression is one of the most prevalent illnesses in women, which significantly affects their quality of life. It has been thought that anxiety and depression are related to cyclical hormonal changes, which may be affected by TL (
In the present study, the prevalence of requesting ROS after TL was 3%. Age at the time of sterilization can affect desire for ROS. Women younger than 30 years old at the time of sterilization were more likely to request reversal than women above the age of 30 (80 vs. 20%). There were significant differences in pre-sterilization counseling between the women requested reversal versus those not requested reversal. From 5 ROS women, nobody did receive any pre-sterilization counseling from a physician or healthcare workers.
Previous studies have indicated several factors predicting desire for ROS (
Young age at sterilization, pre-existing emotional disorders, new marriage, and a history of unreliable contraceptive method increased the likelihood of a request for ROS. Women requesting TL should be advised that TL is permanent if no further tubal surgery is performed and that ROS is feasible but involves expensive operation (
In this study, we aimed to examine various parameters that might predict the incidence of regretting sterilization in women with TL. Age at the time of sterilization, pre-sterilization counseling, score of PBLAC, and the number of days of bleeding was evaluated as predictors for regretting sterilization. In addition, the length of menstrual cycles was negatively associated with regretting their decision. We found a significant difference in the age at the time of sterilization under 30 years between the women regretting versus those not regretting their sterilization. Young age at sterilization was the strongest predictor for post-sterilization regret (
Additionally, the other factor significantly associated with regret is counseling before sterilization (
More knowledge about the potential influencing factors, which have a strong association with regretting the sterilization decision and are easily identifiable before sterilization, is definitely valuable in counseling to avoid regrets. Motivators who may not be doctors in our society need to be informed of the influencing factors prior to counseling women for TL (
Although post-sterilization regret is hardly avoidable, certain groups such as women under 30 years need specific counseling before taking such a major decision like TL (
There are potential limitations to consider in interpreting the results of this study. First, expressing post-sterilization regret is generally an attitudinal measure for which there is no standardized definition. For this reason, these rates may overestimate true sterilization regret. Second, we could not assess the method of TL because women did not have information about the type of sterilization.
The results showed that complications due to sterilization are the main causes of post-sterilization regret. Therefore, it is necessary to pay due attention to mentioning the probable complications of the procedure such as menstruation disorders, sexual dysfunction, and anxiety and depression in women during the pre-sterilization counseling; post-sterilization counseling is also encouraged for increasing satisfaction rate in these volunteers.