Dear Editor,

We reviewed “Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation” and found the results to be an important contribution for the period studied.1 The study compared the effectiveness and safety of IUDs and female permanent contraception procedures performed in a cohort of California medical assistance patients based on claims data from 2008 to 2014. The authors excluded all procedures during the first 6 weeks post-partum. In this large cohort of more than 83,000 patients, they reported slightly lower pregnancy rates in hormonal IUD than permanent contraception or copper IUD patients in adjusted analyses. The authors also reported fewer claims for complications and additional procedures with IUD placement.

We found the reported data to be supportive of clinical practice during the period analyzed and important information to share with the medical community. However, we were surprised that, in the “Discussion”, the authors did not review changes in surgical practice that have evolved since 2014. Since the early 2010s, an increasing proportion of permanent contraception procedures are bilateral salpingectomies rather than occlusive procedures,2 the latter of which likely comprised the overwhelming majority of procedures included in this analysis. National guidelines support this change in technique, sparked by both theoretical higher efficacy and the potential for greater ovarian cancer protection compared to occlusion procedures.3,4

The authors conclude that IUDs work just as well or better than permanent contraception, as typically performed in 2014 and earlier, with fewer complications. The authors also comment that “desire for reversal…is known to occur” and is a reason to counsel specifically about IUDs for patients, particularly Medicaid patients, interested in permanent contraception. Recent data support that regret after a permanent contraception procedure is a function of age at the time of the interview and that the vast majority of patients do not express regret.5 We hope that clinicians do not interpret the findings from this study as a reason to convince patients that IUDs are a “better” choice for patient seeking permanent contraception because of the risk of regret, and especially since tubal occlusion is no longer favored in contemporary practice. Rather, these data serve as an important reminder of why removing entire tubes provides a better option for permanent contraception for those who desire it.