Prepare for your USMLE Step 2 CK with a question focusing on obtaining and interpreting the elements of a focused history for a patient presenting for permanent contraception (sterilization).
A 23-year-old woman, gravida 0, presents to the office to discuss contraception. She does not want children and does not desire to become pregnant. She is interested in learning about sterilization. Her sex partners have all been biologically female, and she has had a single, long-term partner for the past year. Her medical history is notable for severe endometriosis, chronic pelvic pain, and an appendectomy for a ruptured appendix. She takes oral contraceptive pills (OCPs) for her endometriosis, which reduces pelvic pain somewhat. The physical exam reveals a 4 cm well-healed incision in the right lower quadrant; on a bimanual pelvic exam, the patient experiences generalized pelvic discomfort, and the uterus has poor mobility. Comprehensive contraceptive counseling is provided. The patient is surprised to learn there are so many options and decides to research long-acting reversible contraceptive (LARC) methods. At this time, why is permanent sterilization contraindicated in this patient?
A. Uncertainty about permanent contraception
B. Having exclusively female sexual partners
C. Age < 25 and lack of living children
D. Severe pelvic adhesive disease
E. Sterilization is not contraindicated in this patient
Scroll down for the correct answer!
The correct answer to today’s USMLE® Step 2 CK Question is…
A. Uncertainty about permanent contraception
Before we get to the Main Explanation, let’s see why the answer wasn’t B, C, D, or E. Skip to the bottom if you want to see the correct answer right away!
Incorrect answer explanations
Today’s incorrect answers are…
B. Having exclusively female sexual partners
The biological sex and gender of a person’s partner(s) is not a contraindication for providing permanent sterilization.
C. Age < 25 and lack of living children
There is no association between the number of living children a person has and the likelihood of regretting permanent sterilization, though a young age at the time of sterilization is associated with regret of permanent sterilization. Despite this, medical ethicists conclude that paternalism and infringing on one’s reproductive autonomy are worse than allowing a patient to make a well-informed decision that they may regret later. Therefore, neither young age nor low parity are contraindications to the procedure in a well-counseled patient.
D. Severe pelvic adhesive disease
Endometriosis and ruptured appendicitis can both lead to severe pelvic adhesive disease, which is also suggested by poor mobility of pelvic structures on exam. Pelvic adhesions do increase the risk of surgical complications. However, patients have the right to reproductive autonomy, and a well-informed patient may still choose permanent sterilization, even if she chooses to stay on OCPs to control pain or bleeding symptoms or is not a perfect surgical candidate.
E. Sterilization is not contraindicated in this patient
At the end of this encounter, the patient expresses uncertainty regarding her desire for permanent contraception by stating her intention to learn more about LARCs. Therefore, this patient should not undergo sterilization until she confidently rejects LARCs in favor of permanent contraception.
Main Explanation
Sterilization, also known as permanent contraception, is a surgical procedure that is intended to permanently prevent future pregnancies. The only indication for permanent contraception is a patient’s desire for the procedure. Likewise, the only absolute contraindication to sterilization is the lack of consent from a fully informed patient. This means that for the patient to provide consent, she must be free from any coercion and truly understand all the options and the implications of her decision. At the end of this encounter, the patient expresses uncertainty about permanent contraception by stating her desire to learn more about LARCs. Therefore, performing a sterilization procedure on this patient is contraindicated until she confidently rejects all other forms of contraception in favor of sterilization.
Although patient desire is the only indication for sterilization, numerous patient factors may be obtained in history and exams that make alternative forms of contraception more favorable, as detailed in the table below. The patient should be counseled on these alternatives to obtain informed consent. Additionally, the risk of unintended pregnancy should be weighed against the risks of surgery, and this should be discussed with the patient to obtain informed consent.
It is important for the counseling provider to clearly explain all the relevant medical facts and to make a medically sound contraceptive recommendation. For example, the physician in the vignette should inform the patient of her increased risk of regret due to her young age, as well as the potential increased risk of surgical injury due to suspected adhesive disease from endometriosis, and that for these reasons, a LARC is a better option to consider right now. However, the final decision to proceed with sterilization should always lie with the well-informed patient and may be based on personal preferences. Therefore, if the patient returns with strong, clear convictions desiring sterilization, it would be appropriate to proceed with the procedure at that time.
Major takeaway
The only absolute contraindication to sterilization is the lack of consent from a fully informed patient. Informed consent requires that patients are free from coercion and understand all of their contraceptive options and the implications of their decision. A sterilization procedure should not be performed on patients who express uncertainty about the decision.
References
1. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Gynecology (2019). ACOG Practice Bulletin No. 208: Benefits and Risks of Sterilization. Obstetrics and gynecology, 133(3), e194–e207. https://doi.org/10.1097/AOG.0000000000003111
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