Objective: To determine if interval tubal sterilization leads to a change in female sexual interest or pleasure and to identify predictors of a positive or negative effect.

Methods: Our study population comprised 4576 women enrolled in a prospective, multicenter cohort study between 1978 and 1983. Potential demographic, clinical, and surgical predictors of sexual outcome were tested for significant variation from the overall pattern of unchanged, increased, and decreased sexual interest and pleasure.

Results: Over 80% of the 4576 study women reported no consistent change in either sexual interest (80.0%) or pleasure (81.7%) after interval tubal sterilization. Among women with consistent change, positive effects were reported ten and 15 times more often than negative effects for sexual interest and pleasure, respectively. All subgroups of women, except for those with poststerilization regret, were significantly (P < .05) more likely to experience increased rather than decreased interest or pleasure. Women with poststerilization regret were the subgroup most likely to have a negative effect; in multivariate analyses, poststerilization regret was the only factor to be a predictor for decreased interest (odds ratio 4.0) and decreased pleasure (odds ratio 5.1). Similarly, women reporting regret were significantly less likely to report increased interest or pleasure. Whether the regret or the decreased sexual interest or pleasure occurred first is unclear.

Conclusion: Interval tubal ligation is unlikely to result in changed sexual interest or pleasure. Among those with change, the majority experienced positive sexual effects.

^aDivision of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
^bInformation Systems Support Services for the Centers for Disease Control and Prevention, TRW Systems & Information Technology Group, Atlanta, Georgia, USA

This study was supported by an interagency agreement (3-Y02-HD41075-10) with the National Institute of Child Health and Human Development.

The US Collaborative Review of Sterilization Working Group: Design, Coordination, and Analysis Center, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia. Principal Investigator: Herbert B. Peterson, MD; Project Officer: Joyce M. Hughes; Project Associates: Zhisen Xia, PhD, Lynne S. Wilcox, MD, Lisa Ratliff Tylor; Project Consultant: James Trussell, PhD; Data Collection Centers Project Directors: Norman G. Courey, MD, CM, State University of New York at Buffalo, Erie County Medical Center, Buffalo, New York; Philip D. Darney, MD, MSc, University of California, San Francisco, San Francisco, California; Ernst R. Friedrich, MD, Washington University School of Medicine, St. Louis, Missouri; Ralph W. Hale, MD, Roy T. Nakayama, MD, Kapiolani Medical Center, Honolulu, Hawaii; Jaroslav F. Hulka, MD, University of North Carolina School of Medicine, Chapel Hill, North Carolina; Alfred N. Poindexter, MD, Baylor College of Medicine, Houston, Texas; George M. Ryan, MD, Edwin M. Thorpe, MD, University of Tennessee School of Medicine, Memphis, Tennessee; Gary K. Stewart, MD, Planned Parenthood of Sacramento, Sacramento, California; Howard A. Zacur, MD, Lucas Blanco, MD, Johns Hopkins University School of Medicine, Baltimore, Maryland.

(Obstet Gynecol 2002:100:511-517. © 2002 by The American College of Obstetricians and Gynecologists.)

About 26% of US women aged 15-44 years who have ever married have undergone tubal sterilization.¹ With so many healthy women choosing tubal sterilization, it is essential that the health effects, including the potential physiologic and psychologic effects, of the procedure be fully understood. Studies assessing the effects of female sterilization often include some measurement of its impact on sexual functioning. Tubal ligation studies conducted in the United States and Europe report no impact on frequency of sexual intercourse^2,3 or a significant short-term increase in mean coital frequency.^4,5 Studies in which respondents were asked about changes in sexual desire report decreased desire among less than 2-5% and increased desire among 21-25% of respondents.^3,6 Improvements in sexual satisfaction were reported by between 6-55% of respondents, whereas 0-7% reported deterioration.^2-4,7,8 Prior studies were primarily descriptive because of small sample sizes that prevented discrimination of different risks among subgroups of women. The US Collaborative Review of Sterilization, which represents the largest US cohort of women undergoing tubal sterilization, was used to evaluate whether specific subgroups of women were significantly more likely to experience increased or decreased sexual interest or pleasure over 2 years after tubal sterilization.

Materials and Methods

The US Collaborative Review of Sterilization study methods have been described in detail.⁹ Briefly, study approval was granted by the Institutional Review Boards at all 15 participating US medical centers. Women aged 18-44 undergoing tubal sterilization by a method under study at a participating site from 1978 through 1987 were eligible for enrollment. Participants gave informed consent and were interviewed preoperatively by trained nurse-interviewers who used a standardized questionnaire. An extensive medical and reproductive history as well as a detailed record of the sterilization procedure were obtained. Approximately 1 month after sterilization and annually thereafter, women were interviewed by telephone for details of postoperative events. The US Collaborative Review of Sterilization study follow-up was completed in 1994.

A total of 12,138 women undergoing tubal sterilization enrolled in the US Collaborative Review of Sterilization. However, only women enrolled before September 1983 (n = 7193) used follow-up forms that contained questions related to sexual interest and pleasure. These forms were used to collect the first 2 or 3 years of follow-up information (completed by 1985) and contained two questions dealing with changed interest in and pleasurable feelings during sexual activity: 1) Has tubal sterilization affected your sexual interest; that is, since your tubal sterilization operation, would you say you had less sexual interest, more, or about the same sexual interest compared with before the operation? 2) Has tubal sterilization affected your pleasurable physical feelings during sexual relations; that is, since your tubal sterilization operation, would you say you had less, more, or about the same pleasurable feelings during sexual relations compared with before the operation?

This analysis was limited to women who answered both questions at the first and second years of follow-up (n = 6198). We did not include data on sexual interest and pleasure for the third year of follow-up because they were incomplete for a large portion of our sample. To study only the effects of sterilization on sexual function, women undergoing concurrent vaginal delivery, cesarean delivery, or abortion procedures were excluded from the main analysis and analyzed separately. The main analysis includes only women undergoing interval sterilization (n = 4576). For the analysis on pleasurable feelings during sexual activity, another 47 women were removed because they responded "not applicable; not having sex" to the pleasure question at one or both follow-up interviews.

Women who consistently reported "more" to a question were categorized as "increased," and women who consistently reported "less" were categorized as "decreased." All women who responded to a question "same," or who reported inconsistently at the first and second follow-up years, were combined into a "no-change" category. The pattern of no change, increased, and decreased poststerilization interest and pleasure was evaluated. Demographic, clinical, or surgical factors that could disrupt the overall pattern of sexual outcome were assessed. Age, race, education, marital status, and number of children were chosen as demographic characteristics. History of gynecologic conditions (endometriosis, pelvic inflammatory disease, uterine leiomyomata, or ovarian cysts), history of abortion, history of pelvic or abdominal surgery, chronic illness (asthma, diabetes, cancer, thrombotic disease, sickle cell disease, chronic obstructive pulmonary disease, or cardiac, thyroid, or renal disease), type of birth control used in the month before the sterilization procedure, laparotomy versus laparoscopy as the surgical approach, intended method of tubal occlusion, and poststerilization regret were chosen as potential clinical or surgical influences on poststerilization sexual interest or pleasure. Women were considered to have poststerilization regret if they answered "No" to the following question: "Do you still think tubal sterilization as a permanent method of birth control was a good choice for you?" For each subgroup of a potential predictor, we determined separately the proportion and 95% confidence interval (CI) for women with no change, increased, or decreased sexual interest or pleasure. The CIs around each proportion for no change, increased, and decreased were compared; if any two CIs overlapped, then the subgroup was considered to be in significant violation to the overall pattern of no change, increase, or decrease. Multivariate logistic regression models adjusted for the study site were created for the four sexual function outcomes: increased interest, decreased interest, increased pleasure, and decreased pleasure. Stepwise modeling allowed factors with a univariate P .2 to enter the model and factors with a multivariate P .05 to remain in the model.

Results

Approximately 45% of the 4576 women studied were 30 or younger, and 75% were 35 or younger at sterilization (Table 1). The majority had completed high school (82.8%), were white non-Hispanic (65.8%), or black non-Hispanic (28.5%), were married (63.9%), and had children (93.1%).

Most women reported no consistent change in their sexual interest or pleasure after sterilization (Table 2). Among the women classified as no change, 69.7% reported "same" interest, and 71.0% reported "same" pleasure, at both follow-up interviews. Of the remaining women, 29.4% and 28.4% reported "same" at one follow-up interview and either "more" or "less" at the other, respectively. Only 0.9% and 0.6% reported "more" at one interview and "less" at the other, for interest and pleasure, respectively. Among women who reported inconsistently, the time since sterilization had no effect on the responses; similar numbers of women went from "more" to "same" as from "same" to "more," and likewise for the other four possible inconsistent combinations. For women with consistent change, increased interest and pleasure were reported over ten and 15 times more often, respectively, than decreased (Table 2). The poststerilization outcome was similar for sexual interest and pleasure. Excluding women who were not sexually active (n = 47), 88.1% (n = 4012) of women at the first annual follow-up and 91.3% (n = 4145) at the second reported an equal effect on sexual interest and pleasure. Only 0.2% (n = 10) at the first and 0.3% (n = 12) at the second interview reported opposite effects.

The data suggest that in general, interval tubal sterilization has a null or positive effect on female sexual function (Table 2). Therefore, focusing on risk factors of decreased interest or pleasure in this population might unnecessarily eclipse the overall harmless or beneficial effect. Our main analytic method tests potential factors for significant violation of the overall pattern that the majority of women experience no consistent change in sexual interest and pleasure after sterilization, and among those who change, more experience an increase than a decrease. Of the demographic variables considered (Table 2), none violated the overall pattern, as shown by nonoverlapping CIs for the percentage with no change, increased, and decreased sexual interest and pleasure. Again, the pattern held for all the clinical and surgical factors assessed (Table 3), except for regret. Among the few women (n = 147) who reported regret at any time during their 2-year follow-up, equal proportions experienced increased as decreased sexual interest and pleasure (Table 3). Although the proportion without consistent change was higher among women with regret, there was no significant difference between women with regret and women without regret in the frequency of inconsistent responses. Although women with regret comprised only 3.2% of the study population, they accounted for 12.5% of those with decreased interest and 16.0% of those with decreased pleasure. Age at sterilization, as well as the timing of the procedure relative to the birth of the youngest child, have been repeatedly associated with poststerilization regret.¹⁰ Although a higher proportion of younger than older women in this study reported a decrease in interest and pleasure, only 2.6% and 1.7% experienced decreased interest and pleasure, respectively, whereas 18.2% and 16.6% experienced an increase (Table 2). In multivariate analysis, poststerilization regret was the only factor associated with all four sexual function outcomes: increased interest (odds ratio [OR] 0.3, 95% CI 0.2, 0.6), decreased interest (OR 4.0, 95% CI 2.0, 8.3), increased pleasure (OR 0.3, 95% CI 0.2, 0.6), and decreased pleasure (OR 5.1, 95% CI 2.3, 11.4).

Women whose sterilization procedure was conducted postpartum or postabortion were excluded from our main analysis. However, a separate analysis of these women (n = 1622) found that 86% had no change in sexual interest and 88% no change in pleasure; 11% reported increased and 3% decreased interest; and 10% experienced increased and 2% decreased pleasure.

Of the 4576 women, 6.9% were childless at sterilization. These women were no different from the remaining women in their pattern of sexual interest and pleasure (Table 2). Among the 47 women who were excluded from the pleasure analysis because they responded to this question "not applicable; not having sex," all but one experienced no change in interest (97.9%), with the remaining subject having increased interest. Therefore, among women reporting no sexual relations, abstinence was not due to a change in sexual interest after sterilization.

Discussion

Consistent with previous, smaller studies, the majority of women (four of five) reported no change in sexual interest or pleasure after interval tubal sterilization. Furthermore, the proportion without change was similar to and lay within the range of proportions found in other study populations.^2-4,6-8 Among women with consistent change, increased interest and pleasure occurred over ten times more frequently than decreased, confirming previous findings that substantially more women report positive than negative sexual effects.^2-4,6-8

If tubal sterilization had no effect on sexual libido or enjoyment, we might expect the majority to report no change and the remaining to report improvement and deterioration equally. However, for every subset of presterilization characteristics considered, interest and pleasure increased for many more women and decreased for far fewer women than would be expected by chance alone. The only subgroup of women for which interval tubal sterilization appeared to have no effect were women who regretted the sterilization. Even with regret, the majority's experience remained unchanged; however, an equal number of subjects experienced increased as decreased interest and pleasure. One previous study compared women satisfied with their sterilization decision (n = 612) with those unsatisfied (n = 47) and found no differences in libido, coital frequency, or sexual satisfaction, but significant differences in level of tension in sexual life, sexual excitement, and changed perception of femininity.³ In that study, the majority who expressed lack of excitement in sexual life or feelings of changed femininity were those who regretted their decision. However, in our study, although significantly more women who regretted their decision had decreased sexual function than did the overall cohort, the majority of women with negative sexual effects did not regret. We can speculate that the complex psychologic nature of the regret experience may influence a couple's interpersonal relationship and reflect upon their sexual life. However, we are uncertain whether the regret or decreased sexual interest and pleasure occurs first.

We conclude that, in general, tubal sterilization has a positive effect on sexual function. The effect is probably primarily behavioral, due to removal of the fear of unwanted pregnancy, and possibly indirectly biologic, due to stopping a method of birth control that may have had undesirable side effects. Supporting both hypotheses, women in this study who used barrier methods in the month before sterilization experienced the most change and improvement, whereas women whose prior method of contraception was their husband's vasectomy reported the least change. Further evidence for an indirect effect comes from reports that fertile wives of husbands who undergo vasectomy have significant increases in their sexual desire⁶ and coital frequency⁵ after the vasectomy. Although the current study includes a comparison group of wives of men undergoing vasectomy, their follow-up interviews did not contain the sexual adjustment questions. Two studies^6,11 reported higher rates of sexual improvement in wives of men who underwent vasectomy than for women with tubal sterilization. However, a third study⁵ found no difference and even a significant increase in coital frequency at the first follow-up year for only the tubal group. If there is a difference in the reported sexual effects of male and female sterilization, the difference could well be attributed to differences in couples choosing tubal sterilization versus vasectomy. The National Survey for Family Growth has repeatedly found that couples who choose tubal sterilization differ from those who select vasectomy with regard to race, education, and reasons for sterilization.¹

A few studies compared women undergoing tubal sterilization with women using nonpermanent methods of birth control.^5,7,12 Although each study's data show more improvement in sexual satisfaction among the sterilization group, not all results are statistically significant. Two significant studies support our findings of tubal sterilization's effect on sexual libido and pleasure. In a report by Shain et al, women who underwent sterilization experienced a significant, short-term increase in coital desire and frequency, whereas women not planning sterilization had a significant decrease in desire.⁵ At the British site of a World Health Organization study, women using female sterilization reported increased "positive pleasure from intercourse" compared with baseline, whereas women using nonpermanent methods reported significantly decreased pleasure.¹²

Although this study's data were collected more than 15 years ago, the methods and approximate annual numbers of tubal sterilizations remain unchanged.^13-15 Importantly, these data represent the largest US cohort of women undergoing tubal sterilization to date, and over 81% of the women responded to the first and second annual follow-up interviews. The use of self-report to assess a changed sexual function is subject to underreporting bias arising from the sensitivity of the subject matter; however, 95.6% of subjects interviewed at both follow-up years responded to the two questions on sexual function, and therefore any bias would have minimal effects. Unlike previous studies, we considered only consistent responses to be true changes in sexual outcome. Although this definition of change does not account for women who report change at just one time point, it reduces the influence of temporary changes occurring around the time of the follow-up telephone interview. Because our follow-up on sexual factors covers only 2 years, and previous studies have short follow-up periods or small study populations, we cannot be certain that the positive effects of sterilization on sexual interest and pleasure persist over a longer time.

References

1. Abma JC, Chandra A, Mosher WD, Peterson L, Piccinino L. Fertility, family planning, and women's health: New data from the 1995 National Survey of Family Growth (DHHS publication no. PHS 97-1995). Vital Health Stat 1997;23:1-114.

2. Cooper P, Gath D, Rose N, Fieldsend R. Psychological sequelae to elective sterilization: A prospective study. Br Med J 1982;284:461-4.

3. Kjer JJ. Sexual adjustment to tubal sterilization. Eur J Obstet Gynecol Reprod Biol 1990;35:211-4.

4. Rubenstein LM, Benjamin L, Kleinkopf V. Menstrual patterns and women's attitudes following sterilization by Falope rings. Fertil Steril 1979;31:641-6.

5. Shain RN, Miller WB, Holden AE, Rosenthal M. Impact of tubal sterilization and vasectomy on female marital sexuality: Results of a controlled longitudinal study. Am J Obstet Gynecol 1991;164:763-71.

6. Bean FD, Clark MP, South S, Swicegood G, Williams D. Changes in sexual desire after voluntary sterilization. Soc Biol 1980;27:186-93.

7. Richards JM Jr, Kohler CL, Ryan WG, Jackson JR, Goldenberg RL. Contraceptive female sterilizatin in Alabama: A replication of the WHO study. Contraception 1991;43:325-33.

8. Smith EM, Friedrich E, Pribor EF. Psychosocial consequences of sterilization: A review of the literature and preliminary findings. Comp Psych 1994;35:157-63.

9. 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.

10. Hillis SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: Findings from the United States collaborative review of sterilization. Obstet Gynecol 1999;93:889-95.

11. Alder E, Cook A, Gray J, Tyrer G, Warner P, Bancroft J. The effects of sterilization: A comparison of sterilized women with the wives of vasectomized men. Contraception 1981;23:45-54.

12. Cooper JE, Bledin KD, Brice B, Mackenzie S. Effects of female sterilization: One year follow-up in a prospective controlled study of psychological and psychiatric outcome. J Psychosom Res 1985;29:13-22.

13. Wilson EW. The evolution of methods for female sterilization. Intl J Gynecol Obstet 1995;51 Suppl 1:S3-S13.

14. Peterson HB, Hulka JF, Phillips JM, Surrey MW. Laparoscopic sterilization: American Association of Gynecologic Laparoscopists 1991 membership survey. J Reprod Med 1993;38:574-6.

15. Chandra A. Surgical sterilization in the United States: Prevalence and characteristics, 1965-95 (DHHS publication no. PHS 98-1996). Vital Health Stat 1998;23:1-33.

Address reprint requests to: Caroline Costello, MPH, Centers for Disease Control and Prevention, Mailstop K34, 4770 Buford Highway, Atlanta, GA 30341; E-mail: ccostello@cdc.gov

Received September 18, 2001.
Received in revised form February 14, 2002.
Accepted March 14, 2002.