Women's Health special issue. Credit: Julia Yellow for The Washington Post. (Julia Yellow for The Washington Post)

When women don’t want to conceive a child, many consider long-term birth control such as an intrauterine device (IUD), which can prevent pregnancy for up to 12 years, or a tubal ligation, a permanent procedure that blocks the fallopian tubes. But not every doctor is on board with those options. Why do some refuse to provide those methods of contraception?

In some cases, the justification is medical: a current pregnancy, significant risks from the anesthesia needed for a tubal ligation, or a uterine abnormality that might make inserting an IUD dangerous. However, says Jen Gunter, a San Francisco area OB/GYN, "there are really very few medical reasons a woman can't have an IUD."

But some providers refuse to insert IUDs because of misconceptions about their safety and function, especially in women who have not had children. A 2012 survey of medical providers found that 30 percent mistakenly thought the devices are not safe for women without children. And many seem particularly reluctant to insert IUDs in adolescents. (Current practice guidelines say that adolescents and women who have not had children are candidates for IUD insertion.)

Another survey conducted in 2014 found that among the 4 percent of providers who didn't perform any IUD insertions in the past year, almost a quarter were concerned that the IUDs are a method of abortion. (They aren't, according to the American Congress of Obstetricians and Gynecologists: Although IUDs can prevent an egg from being fertilized, they cannot disrupt the implantation of a fertilized egg.) Compared with condom use, which fails 18 percent of the time, IUDs fail as little as 0.2 percent of the time. Contraceptive pills — the most popular form of birth control — involve putting hormones in your body; they fail about 9 percent of the time, in some cases because women don't take the pill when they are supposed to do so.

Doctors' hesitancy to provide IUDs stems, in part, from lingering memories of the Dalkon Shield, a device that was pulled from the market in 1984 after causing serious medical problems, including perforations and scarring infections, in some women. Today, though, IUDs are considered safe, and more women want them than ever. According to the Centers for Disease Control and Prevention, IUD use increased fivefold between 2002 and 2013.And earlier this year, Planned Parenthood's president, Cecile Richards, told CNN that demand for IUDs increased substantially after last November's election.

Nevertheless, Gunter says, she hears about providers refusing to implant IUDs “all the time.” She encourages women to advocate for themselves if they meet resistance from their provider — or go to another provider who recognizes the devices’ merits.

Tubal ligations are trickier. Sterilization — usually by tubal ligation — is the second-most-popular form of contraception in the United States. However, some women who get their tubes tied regret their decision, especially those who have the procedure done at a young age. Concern about those regrets, enthusiasm about IUDs, and the general irreversibility of tubal ligation cause providers such as Gunter to challenge women who think they want the procedure.

“It’s all in how you discuss it with the patient,” she says. “Sometimes surgeries require more thinking beforehand. But I would also expect that people would present this in a kind, non-patriarchal way.” Since tubal ligation involves anesthesia and surgery, it carries a degree of risk. For some women, though, especially those who have had complications with IUDs, the risk is worth it.

Ultimately, the decision to move ahead with sterilization, an IUD or another form of long-term contraception is a personal one, doctors said, and patients must find providers who can help them reach their goals.

Beyond that Gunter has another suggestion: If you have a long-term male partner, ask him to get a vasectomy. Though far less reversible than an IUD, the procedure is cheaper than tubal ligation and simpler to perform.” It’s a minor outpatient surgical procedure that involves no [general] anesthetic,” she says. And it has no side effects for a woman — aside from a serious conversation.

Learn more: cdc.gov/reproductivehealth/contraception.


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