Symptoms limiting exercise in chronic heart failure.

The Times last summer documenting the apparent ease with which childless women in their 20s could obtain the operation.6 Investigation of private sector records may well have prompted the observation that sterilisation is an increasingly widespread solution to the contraceptive problems of theyoung. Public sector statistics, however, show quite the reverse. The General Household Survey data show that fewer than 1% of single men and women in their 20s seek a permanent end to their fertility, and among the married only where high parity has been achieved does the number rise appreciably. Service figures tell the same story. The steady increase noted by Bledin et al in the number of sterilisation procedures carried out on younger women between 1961 and the early 1970s has not continued.7 Though comparable figures are not available for men, operations performed on women under 30 each year have remained remarkably constant in the past decade and the overall increase is solely attributable to the rise in the number of operations performed in the over 30s. Nor is there any evidence, from sterilisation figures at least, ofa widespread trend towards childlessness. In 1983 only 3% of couples with no children had elected to be sterilised. Typical candidates for sterilisation, men and women, are still married couples in their 30s who have completed their families. A further welcome change over the past decade or so in the timing of sterilisation ofwomen deserves mention. Far fewer operations are now performed at the same time as another obstetric event, and far more are performed as interval sterilisations. The number of procedures carried out at the emotionally stressful time of childbirth or delivery fell from two thirds of total inpatient sterilisations of women in NHS hospitals in 1973 to fewer than a quarter 10 years later. Whether the rising trend in sterilisation has now reached its ceiling is hard to tell. The high prevalence in the United States has been almost stationary over the past few years, and the pool of those in Britain who would be prepared to resort to surgery to control their fertility cannot be inexhaustible. On the other hand, the present pace of surgical procedures alone would maintain the current prevalence rate, and on past evidence the upturn in 1983 will almost certainly have been reinforced after the "pill scare" in the autumn of that year. Inpatient figures forNHS hospitals are not available for 1984, but family planning clinics reported a 32% increase in uptake in sterilisation of women and an 18% increase in vasectomy between 1983 and 1984. In addition, new potentially reversible methods of sterilisation are now being developed which could remove the main drawback of this method of family planning. It seems at least likely that the 1976 forecast ofone third ofmarried couples sterilised before the age of 354 will become a reality. Clearly the rising numbers of those electing to be sterilised raise important questions about counselling. Yet there seem no real grounds for the alarm raised in some quarters over the capacity of existing counselling services to cope. Research shows that those at high risk of regret (the target group of sterilisation counselling) are more likely to be younger" and to have been sterilised at times of emotional trauma such as childbirth and abortion,'213 and the evidence suggests that proportionately fewer people are falling into these categories, not more. Counselling is particularly important in the case of voluntary sterilisation, where thse decision must be regarded as irrevocable; and adequate provision of relevant information is vital in every case. But a recent report from the Policy Studies Institute shows that lengthy counselling insisted on indiscriminately is not necessarily in the best interest ofevery client. '4 To give full counselling to all might be as intrusive as to withhold it from the few who need it would be neglectful. However carefully doctors screen their-patients, a small but tragic proportion of those who undergo the operation will subsequently experience ±egret. But even the very best counselling cannot realistically prepare for every eventuality in life. KAYE WELLINGS