Is an operation a drastic way to control birth?

THE pill is the most popular form of contraception used in Britain. But what is our second choice? Condoms? The coil? No, one in five of us opt for sterilisation. According to research published by the European Society of Contraception, the European average for both male and female sterilisation is 10.8 per cent. In Britain, it is 20.8 per cent.

This is 30 times higher than in Italy, for example, where only 0.7 per cent of adults choose sterilisation to prevent conception.

Dr David Geddes, a York GP and medical director of York Primary Care Trust, says there could be many reasons why the British figure was so much higher than the rest of Europe.

Availability and promotion of alternatives, cultural beliefs and the structure of countries' medical services all have a role to play. But, in the end, it all comes down to personal choice.

"Sterilisation can be very liberating," he says. "But this is not a decision that people rush into."

It can, however, be one that they regret. One in five women who are sterilised before they are 30 (the average age for sterilisation in Britain is 32, three years younger than the rest of the EU) go on to regret their decision; and one in six claim their doctors failed them by not fully discussing the options available to them.

Dr Geddes strongly disagreed with the latter, saying patients in Britain were offered ample information, advice and time to talk and consider their decision with the support of GPs, practice nurses and family planning clinics.

"On the Continent there is less provision in terms of family practitioners," he says. "People often have to bypass that level of care completely.

"GPs in this country have a lot of information at their fingertips, and most patients have access to practice nurses who are specifically trained to offer contraception counselling. People, particularly younger people, find it less intimidating to talk to a practice nurse instead of a doctor.

"This counselling is vital in the decision-making process as people have to be confident that their family is complete."

In terms of regret and opportunities for reversal, there is less good news.

While male and female sterilisation are officially irreversible, procedures do exist to join the severed tubes back together. Unfortunately, these procedures do not have a high success rate and can lead to further health risks such as ectopic pregnancy, where the foetus develops outside the womb.

"Vasectomies are reversible too, but you shouldn't expect very positive results," says Dr Geddes. "You are more likely to meet with success if you change your mind within the first year. After that the tubes become damaged and gradually fail to maintain their health.

"We find it is easier to work under the assumption that both male and female sterilisation are irreversible."

British GPs have been accused by sexual health charities in the wake of the new research of failing to adequately lay out the options, and of opting for sterilisation through ignorance and laziness.

"Referring for sterilisation is actually more hassle than sourcing an alternative," says Dr Geddes. "And I don't believe GPs and family planning clinics are not well aware of the alternatives.

"It is our job to provide as much information and support as we can so patients can make the right decision for them."

Among the long-term alternatives to sterilisation are: the pill, which has health implications in terms of thrombosis for women over 35; the mini-pill, which cancels out these concerns but can lead to an irregular menstrual cycle; the coil; three-monthly hormone injections, which can lead to lighter periods on the upside, and weight gain on the downside; and barrier methods.

"One of the messages I would really like to get across is that condoms should not be dismissed as a short-term contraception solution," says Dr Geddes. "They are definitely a long-term alternative.

"Many people are very happy using a barrier method for the rest of their reproductive life."

But if you do opt for sterilisation, the message seems to be: look before you leap.

"Copious amounts of good information are available," says Dr Geddes. "Use it wisely and you are less likely to make a decision you will regret."

:: Sterilisation fact file

- Sterilisation is an operation for men or women that makes them infertile. Male sterilisation (vasectomy) is usually the more effective method, with a 1:2,000 chance of failure. Female sterilisation has a 1:200 chance of failure.

- Female sterilisation involves blocking or cutting the fallopian tubes that carry the egg from the ovaries to the womb, a procedure known as tubal ligation. The operation is done under general anaesthetic and may require an overnight hospital stay.

- Male sterilisation is done by cutting the vas deferens tube that takes the sperm from the testicles to the penis, usually under local anaesthetic. The procedure takes about 15 minutes and may leave the patient in mild pain or discomfort for about a week. A vasectomy does not affect sex drive or ejaculation in any way.

- Sterilisation is only an option for people who have decided that they do not want to conceive at all. This may be because they already have children and choose not to have any more or, less commonly, because a person who has not had children decides that they never want to conceive.

In both situations, a doctor will usually strongly recommend counselling before making a referral. After counselling and a meeting with your GP to discuss the operation and your reasons for choosing sterilisation, the doctor will then write a letter to a specialist (usually a gynaecologist or urologist at your nearest NHS hospital), referring you for treatment.

- By law, anyone can make the decision to be sterilised, but many doctors prefer the consent of both partners in a relationship before referring either one for sterilisation.

- If sterilisation is successful it means other methods of contraception are unnecessary to prevent pregnancy. Neither female sterilisation nor vasectomy provides protection against sexually transmitted infections, however, so a barrier method of contraception such as a condom should still be used if required.

- For both men and women there is a chance that sterilisation will not work, or that the procedure will reverse itself naturally. Both fallopian tubes and vas deferens have the ability to rejoin after separation, although this is an extremely rare occurrence.

- A female sterilisation should become effective immediately, but it is important that the patient is not pregnant before the operation. A contraceptive IUD may be left in the uterus until the next period if there is a risk that a fertilised egg is already present.

- It may take some time before a vasectomy is considered to be successful. Tests must be carried out for a few months after the procedure to check if there is any sperm in the semen. Alternative methods of contraception must be used to prevent pregnancy until at least two of these tests have come back clear.

Facts and figures: NHS Direct

Updated: 09:34 Thursday, July 29, 2004