Laparoscopic tubal reanastomosis versus in vitro fertilization: cost-based decision analysis

Where Microsurgical Tubal Reanastomosis Stands in the In vitro Fertilization Era

Among various options of contraception, bilateral tubal ligation (BTL) remains the most frequently used method for women worldwide even at present. However, up to 30% of those who undergo BTL eventually change their minds and wish to conceive again for a variety of reasons, such as a change in marital status or simply wanting more children. In this case, we can either approach it surgically with tubal re-anastomosis (TA) or by in vitro fertilization (IVF)-embryo transfer. Despite the many advantages of TA which lead the American Society of Reproductive Medicine Committee Opinion to recommend it as the primary choice of treatment in posttubal ligation infertility in 2012, IVF is widely being chosen as the first-line treatment nowadays. This study will review the efficacy of TA in various aspects, including pregnancy rate, cost-effectiveness, feasibility, and accessibility, based on review of the literature and our experience. Through this study, we intend to provide a basis for gynecologists to consider TA as the first option in women who wish to conceive again after BTL in this day and age of IVF.

Economic Evaluation of Medically Assisted Reproduction: A Methodological Systematic Review

BACKGROUND

Medically assisted reproduction (MAR) is a challenging application area for health economic evaluations, entailing a broad range of costs and outcomes, stretching out long-term and accruing to several parties.

PURPOSE

To systematically review which costs and outcomes are included in published economic evaluations of MAR and to compare these with health technology assessment (HTA) prescriptions about which cost and outcomes should be considered for different evaluation objectives.

DATA SOURCES

HTA guidelines and systematic searches of PubMed Central, Embase, WOS CC, CINAHL, Cochrane (CENTRAL), HTA, and NHS EED.

STUDY SELECTION

All economic evaluations of MAR published from 2010 to 2022.

DATA EXTRACTION

A predetermined data collection form summarized study characteristics. Essential costs and outcomes of MAR were listed based on HTA and treatment guidelines for different evaluation objectives. For each study, included costs and outcomes were reviewed.

DATA SYNTHESIS

The review identified 93 cost-effectiveness estimates, of which 57% were expressed as cost-per-(healthy)-live-birth, 19% as cost-per-pregnancy, and 47% adopted a clinic perspective. Few adopted societal perspectives and only 2% used quality-adjusted life-years (QALYs). Broader evaluations omitted various relevant costs and outcomes related to MAR. There are several cost and outcome categories for which available HTA guidelines do not provide conclusive directions regarding inclusion or exclusion.

LIMITATIONS

Studies published before 2010 and of interventions not clearly labeled as MAR were excluded. We focus on methods rather than which MAR treatments are cost-effective.

CONCLUSIONS

Economic evaluations of MAR typically calculate a short-term cost-per-live-birth from a clinic perspective. Broader analyses, using cost-per-QALY or BCRs from societal perspectives, considering the full scope of reproduction-related costs and outcomes, are scarce and often incomplete. We provide a summary of costs and outcomes for future research guidance and identify areas requiring HTA methodological development.

HIGHLIGHTS

The cost-effectiveness of MAR procedures can be exceptionally complex to estimate as there is a broad range of costs and outcomes involved, in principle stretching out over multiple generations and over many stakeholders.We list 21 key areas of costs and outcomes of MAR. Which of these needs to be accounted for alters for different evaluation objectives (determined by the type of economic evaluation, time horizon considered, and perspective).Published studies mostly investigate cost-effectiveness in the very short-term, from a clinic perspective, expressed as cost-per-live-birth. There is a lack of comprehensive economic evaluations that adopt a broader perspective with a longer time horizon. The broader the evaluation objective, the more relevant costs and outcomes were excluded.For several costs and outcomes, particularly those relevant for broader, societal evaluations of MAR, the inclusion or exclusion is theoretically ambiguous, and HTA guidelines do not offer sufficient guidance.

Robotic-assisted laparoscopic tubal anastomosis: Single institution analysis

BACKGROUND

Tubal anastomosis has similar pregnancy rates regardless of approach. Historically, robotic anastomosis has been associated with increased cost and operative time. We sought to perform a contemporary study of these metrics.

METHODS

One hundred and nine patients were identified who underwent robotic-assisted laparoscopic tubal anastomosis. Retrospective analysis of medical records was performed. Phone survey was conducted.

RESULTS

The mean operative time decreased from 140.7 ± 27.0 min in 2013 to 60.0 ± 9.1 min in 2018, with significant downward trend (p < 0.001). The mean cost was $7153.46 ± $1484.41. The pregnancy rate was 59% (35/59), and tubal patency rate was 81% (42/52). Seventy-two percent of patients under 37 years became pregnant.

CONCLUSIONS

There is significant improvement in operative time of robotic-assisted tubal anastomosis with surgical experience. Robotic tubal anastomosis outperformed historical metrics of laparoscopy and laparotomy with regard to operative time and cost in this series.

Role of Reconstructive Microsurgery in Tubal Infertility in Young Women

AIM

Here, we retrospectively analyzed the success rate of reconstructive microsurgery for tubal infertility (RMTI) as a "first-line" approach to achieving tubal reversal and pregnancy after tubal infertility.

PATIENTS AND METHODS

During 9 consecutive years (2005-2014), 96 patients diagnosed with obstructive tubal infertility underwent RMTI (tubal reversal, salpingostomy, and/or tubal implantation) in our centre. The outcomes are presented in terms of tubal reversal rate and pregnancy and correlated with age, level of tubal obstruction, and duration of tubal infertility.

RESULTS

The overall tubal reversal rate was 87.56% (84 patients). The 48-month cumulative pregnancy rate was 78.04% (64 patients), of which seven ectopic pregnancies occurred (8.53%). The reversibility rate for women under 35 yo was 90.47%, with a birth rate of 73.01%. The reconstruction at the infundibular segments favored higher ectopic pregnancy rates (four ectopic pregnancies for anastomosis at infundibular level-57.14%, two for ampullary level-28.57%, and one for replantation technique-14.28%), with a significant value for p < 0.05.

CONCLUSIONS

In the context of IVF "industrialization", reconstructive microsurgery for tubal infertility has become increasingly less favored. However, under available expertise and proper indication, RMTI can be successfully used to restore a woman's ability to conceive naturally with a high postoperative pregnancy rate overall, especially in women under 35 yo.

Laparoscopic Reversal of Tubal Sterilization; A Retrospective Study Over 135 Cases

Objectives: To evaluate the pregnancy and delivery rates of laparoscopic tubal reanastomosis.

Study Design: From 2003 to 2013, 135 laparoscopic tubal reversals were performed according to the four stitch technique. The parameters studied, included positive pregnancy test, miscarriage, ectopic pregnancy, termination of pregnancy, term delivery, post-operative time to conception, post-operative hysterosalpingography, and spermogram.

Results: From the 135 patients operated, 93 fulfilled the inclusion criteria. The age of patients varied from 27 to 47 years old. All ages combined, positive β-HCG blood sample rate was 75.3% (95% CI: 65.0–83.4%) and term delivery 52.7% (95%CI: 42.1–3.0%). The age-adjusted pregnancy and delivery rates were as follows:

27–35 y.o. (n = 23) 95.7% (95%CI: 76.0–99.8%) and 73.9% (95%CI: 51.3–88.9%),

36–39 y.o. (n = 40) 77.5% (95%CI: 61.1–88.6%) and 47.5% (95%CI: 31.8–63.7%),

40–42 y.o. (n = 19) 68.4% (95%CI: 43.5–86.4%) and 52.6% (95%CI: 29.5–74.8%),

43–47 y.o. (n = 11) 36.4% (95%CI: 12.4–68.4%) and 27.3% (95%CI: 7.3–60.7%).

Conclusions: In our series the pregnancy and delivery rates after laparoscopic reversal of tubal sterilization is estimated at 75.3 and 52.7%, respectively. For women with tubal sterilization and no other infertility factors, reanastomosis can restore anterior natural fertility related to age. Laparoscopic reversal should be proposed systematically to patients and performed by well-trained laparoscopists, avoiding potentially the inconvenient and adverse outcomes of an IVF treatment. Although, it may seem a more cost-effective technique compared to robotically assisted reversal, a prospective randomized trial could answer this question.

Declining rates of sterilisation reversal procedures in western Australian women from 1990 to 2008: the relationship with age, hospital type and government policy changes

BACKGROUND

Female sterilisation is usually performed on an elective basis at perceived family completion, however, around 1-3% of women who have undergone sterilisation elect to undergo sterilisation reversal (SR) at a later stage. The trends in SR rates in Western Australia (WA), proportions of SR procedures between hospital types (public and private), and the effects of Federal Government policies on these trends are unknown.

METHODS

Using records from statutory state-wide data collections of hospital separations and births, we conducted a retrospective descriptive study of all women aged 15-49 years who underwent a SR procedure during the period 1st January 1990 to 31st December 2008 (n = 1868 procedures).

RESULTS

From 1991 to 2007 the annual incidence rate of SR procedures per 10,000 women declined from 47.0 to 3.6. Logistic regression modelling showed that from 1997 to 2001 the odds of women undergoing SR in a private hospital as opposed to all other hospitals were 1.39 times higher (95% CI 1.07-1.81) and 7.51 times higher (95% CI 5.46-10.31) from 2002 to 2008. There were significant decreases in SR rates overall and among different age groups after the Federal Government interventions.

CONCLUSION

Rates of SR procedures in WA have declined from 1990 to 2008, particularly following policy changes such as the introduction of private health insurance (PHI) policies. This suggests decisions to undergo SR may be influenced by Federal Government interventions.

Contraception: Menarche to Menopause

Contraception services should be part of routine health care maintenance in reproductive-aged women, especially in light of the fact that approximately 50% of pregnancies in the United States remain unplanned. Barrier methods, especially condoms, may play a role in sexually transmitted disease prevention but are less efficacious for pregnancy avoidance. There are several available hormonal contraceptive options, including the combination hormonal pill, progestin-only pill, combination hormonal patches and rings, injectable progestins, implantable progestins, intrauterine devices (copper or progestin), and permanent sterilization. These methods have varying efficacy, often related to patient compliance or tolerance of side effects.

A Study of Tubal Recanalization in Era of ART (Assisted Reproduction Technology)

INTRODUCTION

Tubectomy remains one of the most popular methods of permanent contraception in developing countries. But about 10% of them regret their decision and 1% want to restore their fertility. Out of many options open method of tubal recanalisation is one of the method of restoring fertility.

AIM

Primary objective was to analyse whether open tubal recanalization is a feasible option for those planning to conceive after tubectomy. Secondary objective was to evaluate the pregnancy rate and analyse the various factors affecting pregnancy rate after tubal recanalization.

MATERIALS AND METHODS

A prospective study, follow-up of 2 year in patients treated with tubal recanalization during 2012-2013 at tertiary teaching hospital. 10 women underwent tubal recanalization procedure. Open surgery was done and the principles of microsurgery were followed meticulously throughout the procedure.

STATISTICAL ANALYSIS

All statistical analyses were performed using SPSS for Windows version 17.0 (SPSS Inc., Chicago, IL, USA). Data were expressed as means, medians, standard deviations, and percentages. We used Student's t-test to compare group means and Fisher-exact test to compare proportions. A p-value of <0.05 was considered significant.

RESULTS

Out of 10 women who went recanalization an overall 50% pregnancy rate was achieved. All pregnancies occurred within 1 year of procedure. When previous sterilisation was done by laparoscopic route, after reversal all of them (100%) conceived while in those sterilised by Pomeroys method the pregnancy rate after reversal was only 16.6%. Following reversal pregnancy was stastically more significant in those with final tubal length of >5cm (p=0.04) and in those with Isthmo-Isthmic type of anastomosis .

CONCLUSION

Open tubal recanalisation remains a feasible option for those planning pregnancy after tubectomy. The important factors for determining the success of operation were age of the patient, time interval between sterilization and reversal, site of ligation, method used for previous ligation and the remaining length of the tube after recanalisation.

Cost and efficacy comparison of in vitro fertilization and tubal anastomosis for women after tubal ligation

OBJECTIVE

To compare cost and efficacy of tubal anastomosis to in vitro fertilization (IVF) in women who desired fertility after a tubal ligation.

DESIGN

Cost-effectiveness analysis.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Cost per ongoing pregnancy.

RESULT(S)

Cost per ongoing pregnancy for women after tubal anastomosis ranged from $16,446 to $223,482 (2014 USD), whereas IVF ranged from $32,902 to $111,679 (2014 USD). Across maternal age groups <35 and 35-40, years tubal anastomosis was more cost effective than IVF for ongoing pregnancy. Sensitivity analyses validated these findings across a wide range of ongoing pregnancy probabilities as well as costs per procedure.

CONCLUSION(S)

Tubal anastomosis was the most cost-effective approach for most women less than 41 years of age, whereas IVF was the most cost-effective approach for women aged ≥41 years who desired fertility after tubal ligation. A model was created that can be modified based on cost and success rates in individual clinics for improved patient counseling.

Effectiveness of in vitro fertilization in women with previous tubal sterilization

OBJECTIVE

The objective was to determine the effectiveness of in vitro fertilization (IVF) on live-delivery rates in women who had previously undergone tubal sterilization.

STUDY DESIGN

We examined first IVF live deliveries for women aged 20-44 years at their first embryo transfer (ET) with history of hospital admission for tubal sterilization in Western Australia (WA). The ET cycles (n=178) were ascertained over the period of 1996 to 2010 using WA hospital records. A control group of subfertile women matched by age was randomly selected (n=178). We used Kaplan-Meier curves and life-table analysis to evaluate the cumulative live-delivery rates.

RESULTS

An overall cumulative live-delivery rate in women who had undergone previous tubal sterilization (31%) was comparable to that of subfertile controls (34%) within the first 24 months. Younger women (aged 20-34 years) with previous sterilization (34%) were slightly more likely to deliver an IVF live baby than older women (aged 35-39 and 40-44 years) (33% and 22%, respectively), although this difference was not statistically significant (p=.449).

CONCLUSION

Women who desire fertility after a tubal sterilization procedure and undergo IVF have rates of pregnancy similar to age-matched subfertile IVF control patients.

IMPLICATIONS

In vitro fertilization success in women who had undergone previous tubal sterilization is similar to that of the subfertile controls and thus does not depend on past fertility. Age is the most important predictive factor in achieving pregnancy.

Robotic-assisted tubal anastomosis with one-stitch technique

The da Vinci^® robotic surgical system has been used more often in recent years for tubal anastomosis (TA) and has been reported to have an increased operative time. A one-stitch technique has been used for the reanastomosis step in laparoscopic TA. To date, publications on robotically-assisted TA (RATA) describe an anastomotic step with multiple (usually four) sutures placed. This retrospective case series reports tubal patency data on patients who underwent RATA with the one-stitch technique; tubal patency was the outcome measure. Eighteen women (ages 27–39) underwent RATA with the one-stitch anastomotic technique in tertiary care medical centers between February 2009 and May 2012. Tubal patency was demonstrated in 16/17 patients (94.1 %), as evidenced by postoperative hysterosalpingogram (HSG) and/or subsequent pregnancies. We report the first case series which shows that RATA with a single stitch for the reanastomotic step is effective in achieving tubal patency as evidenced by postoperative HSG and/or pregnancies.