When Lori Witt began pursuing a tubal ligation at age 27, she said physicians refused to even discuss it with her, telling her she was too young and might change her mind about having children.
For more than a year, Witt tried to get sterilized. Finally she went with her 28-year-old husband to a military medical clinic overseas, where Witt said he was given a vasectomy with few questions asked.
Decades after sterilization became broadly available to women in the U.S., some still have trouble obtaining one of the safest and most effective forms of birth control.
The American College of Obstetricians and Gynecologists says nobody who seeks sterilization should be denied. But some women say the reality can be much different, especially for younger women and those without children.
In interviews and on Internet forums, women report facing resistance and flat-out refusal from health care providers as they seek permanent contraception. Along the way, they encounter sexist and paternalistic attitudes, such as the assumption that all women desire children or that they'll come to regret their decision.
"I've yet to come across a story of a woman without children who was granted sterilization on her first request," said Cristina Richie, a Massachusetts professor whose report on voluntary sterilization among child-free women was published by the Hastings Center, a bioethics research institute.
Julie Palm of Colorado Springs, Colo., received a tubal ligation three years ago when she was 22, but not without a fight.
"When I met with my first OB-GYN, he seemed to struggle with the idea," Palm said. "He was uncomfortable with sterilizing someone so young ... but I refused to back down. He agreed with the point that it was my body."
In addition to the fear of regret, doctors who are reluctant to sterilize a young woman may have misgivings because of their own religious beliefs, concerns about insurance coverage or potential liability, and the fact that other effective forms of long-term birth control exist.
"I strongly discourage it under age 30 because I've seen so many people change their minds," said Dr. John Merling, a family medicine specialist in Wilmington, Ohio. "They come in and are absolutely sure they want it done."
About 13 percent of women who obtain a tubal ligation express regret within 14 years, according to the U.S. Collaborative Review of Sterilization, though the CREST study found rates to be higher among younger, poorer and less-educated women.
But for many women, the potential cost of an unplanned pregnancy — an unwanted child or an abortion — or side effects from other forms of birth control are risks that far outweigh the potential for regret.
"Regret is the competent woman's burden, not the doctor's," said Richie, an adjunct professor at the Massachusetts College of Pharmacy and Health Sciences. "Very few providers of other permanent elective treatments like plastic surgery refuse treatment over fear of regret. Why should sterilization be any different?"
Physicians may fear doing something the patient might later view as detrimental, said Katie Watson, an assistant professor in the medical humanities and bioethics program at Northwestern University's Feinberg School of Medicine. "That's upsetting. No physician wants to feel like they've harmed a patient."
But Watson said the physician's focus should be ensuring that the patient receives adequate counseling beforehand. Informed consent also protects doctors from lawsuits, she said.
"Patients get to make the decisions because they are the ones who have to live with them," she said.
Doctors are significantly more likely to discourage a patient from undergoing surgical sterilization if she is younger, has fewer children and is not in full agreement with her husband, according to a national survey of women's physicians in the U.S. that was published in 2011 in the journal Human Reproduction. Nevertheless, nearly all the physicians said they would help the patient obtain the procedure if she persisted.
In a traditional tubal ligation, the fallopian tubes, which carry the eggs from the ovary to the womb, are burned, clipped, cut or tied to prevent sperm and egg from meeting. Another method, called Essure, involves implanting tiny coils that create a blockage inside the fallopian tubes.
Some doctors say they find that women often aren't aware of long-lasting but reversible alternatives to sterilization, noting that intrauterine devices (IUDs) and contraceptive implants are equally effective at preventing pregnancy and may even be safer.
"Many women see the benefits of closing the door forever so they don't have to think about it," said Dr. Nancy Stanwood, an associate professor of obstetrics and gynecology at the Yale School of Medicine. "But we could do a better job of explaining alternatives. I've certainly had patients come, ready to convince me to do tubal. But when I tell them about alternatives they say, 'Wait, that sounds so much better!'"