Hormonal and ovarian stromal blood supply changes after laparoscopic tubal sterilization: a prospective controlled study

Tubal Ligation and Age at Natural Menopause

OBJECTIVE

To determine the effect of tubal ligation on age at natural menopause, as a marker of long-term ovarian function.

METHODS

Three preexisting population-based cohorts were included in this cross-sectional study. Data from each cohort was analyzed separately. The cohorts were restricted to women who never smoked and had reached natural menopause, without prior hysterectomy or oophorectomy. The following variables were collected: race, age at menarche, age at menopause, history of hysterectomy or oophorectomy, gravidity and parity, tobacco use, and ever use of hormonal contraception. The type of tubal ligation and age at tubal ligation were manually abstracted in cohort 1. For cohorts 2 and 3, history of tubal ligation was obtained from an institutional form, completed by patient report. The primary outcome, age at natural menopause, was compared between the two groups (those with and without a history of tubal ligation).

RESULTS

Inclusion criteria was met by 555 women from cohort 1, 1,816 women from cohort 2, and 1,534 women from cohort 3. Baseline characteristics did not differ between cohorts. The percentage with tubal ligation was the same in all cohorts: 26.0%, 25.5%, and 25.0%, respectively. Women with a tubal ligation were more likely to have had at least one pregnancy and to have used hormonal contraception compared with women without a tubal ligation. There was no significant difference in age at natural menopause in women who underwent tubal ligation (50.1, 49.9, 50.0 years, respectively) compared with those who did not (50.7, 49.6, 50.0 years, respectively). The type of tubal ligation (cohort 1 only) had no effect on age at menopause.

CONCLUSIONS

Tubal ligation did not affect age at natural menopause in the three large cohorts included in this study.

Tubal Ligation and Risk of Endometrial Cancer: Findings From the Women's Health Initiative

OBJECTIVE

Bilateral tubal ligation (BTL) is a common form of birth control in the United States. There are limited, contradictory data examining BTL and the risk of endometrial cancer and none examining type I and type II cancers separately. We investigated the association between BTL and endometrial cancer risk using the Women's Health Initiative (WHI) Observational and Dietary Modification Studies.

METHODS

Demographic information and history of BTL were obtained from the baseline questionnaires from 76,483 WHI participants in the Observational and Dietary Modification Studies. Univariable and multivariable models were used to examine the association of BTL with type I and type II endometrial cancers.

RESULTS

A total of 1137 women were diagnosed with incident endometrial cancer (972 type I and 128 type II) during a mean follow-up of 11.3 years. Overall, 14,499 (19%) women had undergone BTL. There were no statistically significant associations noted between BTL and age at BTL for type I or type II cancers.

CONCLUSIONS

We examined the largest patient cohort to date in an effort to determine the impact of BTL on endometrial cancer risk. In the WHI trial, we observed no overall effect of BTL on the risk of type I or type II endometrial cancer, suggesting that patients undergoing this popular birth control method likely do not have an associated change in their baseline risk for endometrial cancer.

Examination of the ovarian reserve after generation of unilateral rudimentary uterine horns in rats

Objective. The purpose of this experimental rat model study is to evaluate the changes in the ovarian environment after excision of the rudimentary horn. Methods. Ten female Wistar albino rats were used in this study. One cm of right uterine horn length was excised in the first operation. Two months after the first operation, all animals were sacrificed to obtain ovaries for histological examination. Mann-Whitney U test and Student's t-test were used for statistical analysis purposes. Statistical significance was defined as P < 0.005. Results. The number of primordial follicles (P = 0.415), primary follicles (P = 0.959), preantral follicles (P = 0.645), antral follicles (P = 0.328), and Graafian follicles (P = 0.721) was decreased and the number of atretic follicles (P = 0.374) increased in the right ovarian side. Howeve,r this difference was not found to be statistically significant. Conclusion. The results of this experimental rat model study suggest that the excision of rudimentary horn could have negative effects on ipsilateral ovarian functions.

Impact of tubal ligation on ovarian reserve as measured by anti-Müllerian hormone levels: a prospective cohort study

BACKGROUND

Tubal ligation (TL) is considered a very efficient contraceptive method. However, some patients complain of a variety of postoperative symptoms. The objective of this study was to investigate whether ovarian reserve may change after tubal ligation.

STUDY DESIGN

This was a prospective cohort study of 80 fertile women who underwent TL. Ovarian reserve was evaluated by measuring pre- and postoperative (1 year after surgery) serum anti-Müllerian hormone (AMH) levels and transvaginal antral follicular count (AFC). Potential confounding factors were age, body mass index (BMI), smoking, surgical technique and prior contraceptive methods. The Wilcoxon test was used to compare pre- and postoperative (12 months) AMH and AFC, and simple and multiple linear regression were used to evaluate confounding factors.

RESULTS

Fifty-two patients completed the study protocol. The median AMH level was 1.43 ng/mL (interquartile range 0.63-2.62) preoperatively and 1.30 ng/mL (interquartile range 0.53-2.85) after 12 months (p=.23). The mean AFC was 8.0 (interquartile range 5.0-14.0) and 11.0 (interquartile range 7.0-15.0) before and after TL, respectively (p=.12). These differences were not statistically significant. Use of a hormonal contraceptive method prior to TL was significantly associated with a postoperative increase in AMH.

CONCLUSIONS

This study suggests that ovarian reserve is not altered by TL.

Ovarian reserve testing before and after laparoscopic tubal bipolar electrodesiccation and transection

OBJECTIVE

To find out whether tubal sterilization leads to loss of ovarian reserve, we assessed the hormonal and ultrasonographic parameters of ovarian reserve in women who underwent laparoscopic tubal sterilization by bipolar electrodesiccation and transection.

STUDY DESIGN

In this preliminary study, laparoscopic tubal sterilization was performed on 49 healthy women who had voluntarily requested elective surgical sterilization. Among the current ovarian reserve indicators, in the early proliferative phases, preoperative (baseline) and postoperative (third month) serum follicle-stimulating hormone (FSH), estradiol (E2), and anti-Mullerian hormone (AMH) levels, ovarian volume, and antral follicle counts (AFCs) were determined. Analysis of these hormonal and ultrasonographic parameters of ovarian reserve preoperatively and postoperatively was the main outcome measure.

RESULTS

Preoperative and third-month postoperative FSH, LH, E2, and AMH levels did not reveal statistically significant differences (p=0.101, p=0.180, p=0.254, and p=0.079; respectively). The ultrasonographic indicators of ovarian reserve did not change in terms of total ovarian volume and total AFC (p=0.793 and p=0.098, respectively).

CONCLUSIONS

Short-term follow-up study results revealed a slight but non-significant change in the current ovarian reserve markers, especially in the AMH levels.

Tubal sterilization during cesarean section or as an elective procedure? Effect on the ovarian reserve

BACKGROUND

The purpose of this study is to compare the effects of tubal sterilization on the ovarian reserve by means of hormonal and ultrasonographic evaluation during a cesarean section or when performed as a planned interval procedure.

STUDY DESIGN

Fifty women who had undergone tubal sterilization during a cesarean section (n=24) and by minilaparotomy as an elective procedure (n=26) were included in the study. Tubes were ligated with the Pomeroy technique in both groups. The women who had chosen to use barrier method or intrauterine device for contraception (n=30) constituted the control group. Among the women in the control group, two separate control groups were constituted (control 1 and control 2) who were age matched with the women in each study group. Hormone levels including antimüllerian hormone (AMH) and inhibin B and ultrasonographic evaluations were performed on the third day of the menstrual cycle 1 year after the tubal sterilization procedure.

RESULTS

Mean blood estradiol, follicle stimulating hormone and luteinizing hormone levels on the third day of the cycle postoperative 12 months after the surgical intervention did not show any significant differences in the groups with respect to their age-matched controls. There was no significant difference in terms of mean serum AMH and inhibin B levels between the groups and their age-matched controls. However, significantly higher postoperative levels of mean AMH levels were detected in the tubal sterilization during cesarean section group when compared with the minilaparotomy group, and significantly lower postoperative levels of mean inhibin B were detected in the elective tubal sterilization via minilaparotomy group when compared with the cesarean section group. Statistically significant differences were observed in terms of number of antral follicles and mean ovarian volumes being less in the elective tubal sterilization via minilaparotomy group when compared with age-matched controls.

CONCLUSION

Intraoperative cesarean section tubal sterilization seems to be a practical and safe method, and has less effect on the ovarian reserve when compared with planned tubal sterilization by minilaparotomy.

Does bilateral salpingectomy with ovarian retention warrant consideration as a temporary bridge to risk-reducing bilateral oophorectomy in BRCA1/2 mutation carriers?

Risk-reducing salpingo-oophorectomy (RRSO) is the most definitive surgical intervention for ovarian cancer risk reduction among BRCA1/2 mutation carriers. For women who have completed child-bearing but who are not ready for RRSO, bilateral salpingectomy with ovarian retention (BSOR) might serve as a temporary measure while definitive risk-reducing surgery is being contemplated. Here we summarize recent insights into the pathogenesis of hereditary ovarian cancer that might provide a basis for consideration of the proposed BSOR management strategy and outline the evidence for and against this potential risk-reducing intervention. Based on the evidence, we suggest that there may be sufficient merit in this proposed intervention to consider evaluating it formally, perhaps through an intergroup-based clinical trial. In the meanwhile, we believe that BSOR should be considered an investigational risk management option of unproven clinical usefulness, particularly because delay in bilateral oophorectomy theoretically could reduce the protective effect against breast cancer that has been documented in women who have undergone RRSO.

Vascular endothelial growth factor (VEGF) and inducible nitric oxide synthase (iNOS) immunoreactivities in rat ovaries and uterine tubes after tubal ligation: a controlled immunohistochemical study

OBJECTIVE

To evaluate the effects of tubal ligation on ovarian and tubal tissues by means of immunohistochemical evaluation of two hypoxia related mediators: vascular endothelial growth factor (VEGF) and inducible nitric oxide synthase (iNOS).

DESIGN

Fourteen Sprague-Dawley female rats were divided into two groups: a tubal ligation (Pomeroy technique) was carried out on rats in group 1 (n = 7) whereas those in group 2 served as controls (n = 7). Salpingo-oophorectomy was performed in group 1 during the second oestrous period following tubal ligation. Rats in group 2 were submitted to a salpingo-oophorectomy, as well. VEGF and iNOS immunoreactivities in ovarian and tubal tissues were evaluated by means of immunohistochemistry. Immunohistochemical scores and number of antral follicles were compared.

RESULTS

In the ovary, VEGF immunoreactivity was significantly more intense in the granulosa (p = 0.002) and the theca cells (p = 0.001) of rats in group 1 but, in ovarian medulla (p = 0.259) and germinal epithelium (p = 0.209), it was not significantly different from that of rats in group 2. The iNOS immunoreactivity in ovarian granulosa cells (p = 0.073) and germinal epithelial cells (p = 0.805) did not differ between the two groups. The cytoplasmic VEGF (p = 0.001) and iNOS (p = 0.017) immunoreactivities in the uterine tube, were significantly more intense in group 1. However, VEGF immunoreactivity in the lamina propria of the uterine tube (p = 0.209) was of similar intensity in both groups.

CONCLUSION

Tubal ligation may lead to supraphysiological hypoxia as evidenced by increased VEGF and iNOS immunoreactivities in ovarian and tubal tissues.