Reviewer’s report
Title: 
Comparison of various aspects of women’s lives between infertile and
women with and without tubal ligation: a comparative cross-sectional study
Version: 
0 
Date: 
10 Oct 2020
Reviewer's report:
The study deals with important questions about women who experience various
procedures related to pregnancy prevention or are infertile. 
Overall, the study is
well designed with adequate sample sizes. 
However, it was not designed to
determine causal linkages but is framed with language suggesting "effects" of
various actions such as tubal ligation. 
While it may be true that there is some
causal impact, this conclusion cannot be determined with the current
retrospective study design. 
The language should be revised to better reflect the
cross-sectional / associational study design.
Pauls (2010) is cited as finding negative effects on sexual function after TL -
however, that is not correct. 
In fact, the author noted the opposite for the largest
study TL in the review (Costello et al, 2002) - 
"Most women did not report any
changes; however, in those who did, positive effects were more common than
negative. Post-sterilization regret was the only factor to be associated with
negative impact on sexuality." p. 109 
And Pauls' final conclusion is: 
"The
findings of this review suggest that following most gynecological surgery, sexual
function improves." p. 111 
The reference to this work in the current manuscript
is not consistent with these previous findings. 
The exclusion of those being treated with anti-depressants poses a potential
selection bias that may have impacted findings. 
Numbers of potential
participants who were excluded by group (Infertile, TL, Condom) should be
reported.
Additional detail about how and where the recruitment took place and the
percent of women who agreed would be important.
Number of children is a key variable that may be related to findings. 
Including as
a covariate would improve control of factors related to outcome variables. 
It is
possible that those choosing TL are more likely to have higher numbers of
children which could impact many of the outcome variables. 
If not assessed,
should be included as a limitation in the discussion.
As noted in the discussion, regret may be related to the increased negative
psychological state among TL participants. 
This is a weakness in the current
study. 
Overall, the study adds to the knowledge base and provides insights into some of
the cultural and contextual aspects of these issues. 
Addressing the points raised
above would improve the manuscript.
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Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
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Are the methods sufficiently described to allow the study to be repeated?
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from apparent manipulation?
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