Many women across the globe struggle with fertility: Some try to become pregnant but can’t, others are persistently unsuccessful at in vitro fertilization, and many experience the heartbreak of miscarriage. While these women strive for motherhood, others inhabit the opposite end of the fertility spectrum, hoping to avoid pregnancy at any cost — even if it means permanently closing the door to birthing children. Becoming sterile, though stigmatized throughout history, is no longer viewed as the loss of a woman’s femininity, purpose, or worth in most places. Rather, it’s a conscious choice many women make to gain absolute control over their reproductive systems.

A Reproductive Revolution

Prior to the 1960s, contraception was a murky world dominated by condom use and other, less effective methods. It wasn’t until the Food and Drug Administration approved the first oral contraceptive pill in 1960 that birth control became a more mainstream topic. Even still, sterilization, the most extreme form of birth control, was rarely discussed as anything but a necessary medical procedure, mostly on occasions where additional pregnancies would be hazardous to the mother.

After the procedure gradually became safer and less invasive through the development of laparoscopic devices, more and more women began to seek sterilization as a contraceptive method when childbearing was no longer desired. Currently, sterilization can be performed in a variety of ways, including tubal ligation (getting "tubes tied"), and tubal implants, which cause scar tissue to form within — and block — the fallopian tubes. These methods have had, and still have, their share of critics.

Some religious groups vehemently oppose sterilization along with other forms of contraceptives, and sterilization still carries a stigma stemming from coercive practices that have marred the history of family planning in many countries. For example, Pamela Barnes, then-president and CEO of EngenderHealth, wrote that throughout history, women have been forced to sign consent forms for sterilization as prerequisites for care, and some have been forced into consenting based on inaccurate or incomplete medical information. Despite this, the vast majority of female sterilizations performed today are done in a safe and ethical manner. And there are a significant number happening.

According to the Centers for Disease Control and Prevention (CDC), 62 percent of women of reproductive age (15 to 44 years old) were currently using some form of contraception between 2011 and 2013. Of these women, 25.1 percent relied on female sterilization as their contraceptive method, making it the second most popular method behind the pill.

This number may seem high, especially since it excludes sexually active women over the age of 44 for whom sterilization makes more sense due to their approaching menopause. A further breakdown of the CDC’s data reveals this logic may have some basis, since 44.2 percent of the women in the highest age bracket (35 to 44) used some form of sterilization as birth control, and 44 percent of those went with female sterilization rather than having their partner undergo the procedure.

The choice to undergo sterilization did not, however, correlate solely with age. Women with less education were also more likely to rely on their own sterilization than a partner’s vasectomy, and women relying on Medicaid or another state-sponsored plan were more likely than those with private insurance to use female sterilization as contraception.

Sterilization may be the right choice for many women, but the disparity between male and female sterilization is stark — while 25.1 percent of women using contraception relied on female sterilization, only 8.2 percent of women relied on male sterilization (vasectomy). In other words, only about a third as many women relied on male sterilization than on female sterilization. So what gives?

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Getting your tubes tied may be more expensive and risky than your partner getting a vasectomy. Pixabay Public Domain

His Or Hers

Experts say a variety of factors could be influencing the striking dominance of female sterilization over male, none of which have much basis in medicine.

“Vasectomies are the safest, simplest, most cost-effective method of contraception we have,” Dr. Edmund Sabanegh Jr., director of the Clinic for Male Fertility at the Cleveland Clinic Foundation told The New York Times.

He has a point. Studies show vasectomy is 30 times less likely to fail and 20 times less likely to result in postoperative complications than its gynecologic counterpart. Vasectomies are also cheaper, costing less than $1,000 dollars, according to Planned Parenthood, while female sterilization (tubal sterilization) can cost up to $6,000 depending on a patient’s health insurance.

So why aren’t vasectomies anywhere near as widely used as female sterilization? The answer may lie in deeply engrained cultural ideas. Many people still classify contraception as a women’s issue, likely because it’s women who bear the physical weight of an unexpected pregnancy.

“Female sterilization is more popular simply because the burden of reproduction is on the woman,” Dr. Nicole E. Williams, a board certified gynecologist and founder of the Gynecology Institute of Chicago, told Medical Daily in an email. “Many of my patients have complained to me about how hard it is to get their husbands/partners to even go to the doctor for routine exams; it’s certainly hard to get them to get sterilized!”

Another possible reason lies in the association between male sterilization and a loss of virility and libido. Yet, there is no medical evidence to suggest that vasectomies affect sexual performance. The stigma seems to persist nevertheless. This belief may change, though, in light of researchers developing male hormonal contraceptives.

These psychological barriers that prevent men from undergoing vasectomies may trouble some women, but many others are more than ready to take control of their own reproductive systems — often, even before they’ve had a child.

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A young woman may know she never wants to have children, but doctors can be hard to convince. Ashley Webb (CC BY 2.0)

Childless Means Optionless When It Comes To Sterilization

More difficult for society to understand than mothers who wish to be sterilized are the childless women who, for whatever personal reasons, desire sterilization. Compared to the rest of the world, countries like the United States and England are progressive and fair when it comes to women’s health care — abortions are legal, there are several options for birth control, and contraceptives can be obtained for free in some places. Sterilization before children, however, remains something of a taboo.

Holly Brockwell, editor-in-chief of Gadgette, shared her experience trying to obtain a sterilization in her 20s with The Guardian. She explained that many medical professionals met her with “condescension” when she decided she wanted a permanent end to her fertility at just 26. Brockwell said she knew she never wanted children, but that nearly everyone in her life questioned her, including doctors.

She recalled the various reactions to her decision: “You’re too young, you’ll change your mind, who’ll look after you in your old age, how can any woman not want children, how can you be so selfish?”

Brockwell’s experience is not uncommon. Clinicians are not shy about their apprehension to perform a permanent sterilization on young, childless women. “[Sterilization] is most commonly used for women who have completed childbearing,” Williams said. “However, there are some women who have never had children who desire permanent sterilization for many reasons, and some physicians will not honor their request.”

Williams currently has a 34-year-old patient with no children who wishes to be sterilized. Williams said she was the third doctor the patient saw, and has scheduled the surgery for next month. “The reason her other physicians did not proceed with her sterilization is because they told her that she may regret her decision,” she said. “I respect her decision to have control over her body.”

That said, all experts agree that the decision to undergo sterilization should always be a carefully considered one. Though there are certainly some young women who are positive about their decision to be sterilized, the statistics support many clinicians’ apprehension. According to research, women undergoing sterilization at the age of 30 or younger are about twice as likely to regret their decision as those who are sterilized when they’re over 30. Younger women are also 3.5 to 18 times as likely to request information about procedure reversal, and eight times as likely to actually undergo a reversal.

“I have only had one patient regret having been sterilized,” Williams said. “She had been divorced and met a man who had not had children. Unfortunately in this case IVF is the best route to go because reversing permanent sterilization has a very low success rate.”

The majority of women who undergo the procedure, however, are happy with the results. While it has seen its share of controversy and doubt over the decades, its increasing popularity suggests one thing — it looks like it’s here to stay.