The risk of pregnancy after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization

Chronic lower abdominal pain in an elderly female patient: a case report about sigmoid colon fistula and pelvic abdominal infection

An elderly woman patient presented with a history of recurrent right lower abdominal pain accompanied by fever and abnormal vaginal discharge for 36 years worse for two weeks. Conservative medical treatment was ineffective, by laparoscopic exploration combined with intraoperative colonoscopy, the presence of a sigmoid colon fistula and pelvic abdominal infection with foreign bodies were confirmed. It was hypothesized that the occurrence of recurrent right lower abdominal pain and intestinal fistula may be potentially associated with tubal injection sterilization performed 36 years ago.

Pregnancy after Tubal Sterilization in the United States, 2002 to 2015

BACKGROUND

Tubal sterilization is the most commonly used method of contraception in the United States. Because contraceptive effectiveness influences contraceptive selection, we examined typical use failure rates after tubal sterilization in the United States.

METHODS

We estimated rates of pregnancy after tubal sterilization using data from four waves of the National Survey of Family Growth (NSFG), representative samples of U.S. women aged 15 to 44 years, collected in 2002, 2006 to 2010, 2011 to 2013, and 2013 to 2015. Survey weighting was used in survival analysis to examine time to first pregnancy after tubal sterilization. Data from these participants were censored after a tubal reversal procedure, infertility treatment, hysterectomy, or bilateral oophorectomy. Reported pregnancy rates after tubal sterilization procedures were examined by using Kaplan-Meier curves and then multivariable Cox proportional-hazards models to examine the effects of age at tubal sterilization, race/ethnicity, education, Medicaid funding, and postpartum versus interval procedures.

RESULTS

Pregnancy after tubal sterilization was reported by 2.9 to 5.2% of participants across NSFG waves. In the most recent survey wave (2013 to 2015), the estimated percentage of participants with pregnancies within the first 12 months after a tubal sterilization procedure was 2.9%; at 120 months after tubal sterilization, the estimated percentage with a pregnancy was 8.4%. At all the time points examined, pregnancy after tubal sterilization was less common after postpartum procedures than after interval procedures; however, this difference was not evident in multivariable models. In multivariable models, chance of pregnancy decreased with age at time of tubal sterilization. Race/ethnicity, education, and Medicaid funding were not consistently associated with pregnancy after tubal sterilization.

CONCLUSIONS

These data suggest that there may be nontrivial rates of pregnancy after tubal sterilization.

U.S. Selected Practice Recommendations for Contraceptive Use, 2024

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Two Consecutive Ruptured Tubal Ectopic Pregnancies after Interval Bilateral Tubal Ligation

Background

Bilateral tubal ligation (BTL) is an effective permanent method of birth control that is surgically performed to block the woman's fallopian tube and prevent the egg from meeting the sperm. It is preferred by women or couples who have achieved their reproductive potential and do not desire pregnancy. BTL carries a low risk of method failure with a subsequent pregnancy which is likely to be ectopic. We present a case of two consecutive ruptured tubal ectopic pregnancies following an interval BTL.

Case Presentation

A 40-year-old female, with 7 living children, who previously underwent an interval BTL, presented with acute abdominal pain for 2 days and amenorrhea for 6 weeks. She was stable but had generalized abdominal tenderness, guarding and rebound tenderness, and cervical motion tenderness. Her urine HCG was positive, and a trans-abdominal ultrasound scan revealed a tender echo-complex right adnexal mass, free fluid in the Cul-de-sac, and an empty uterine cavity, consistent with a ruptured right ectopic pregnancy. An emergency exploratory laparotomy was done with findings of a ruptured right distal tube containing products of conception, hemoperitoneum, and previous tubal ligation and left salpingectomy. A right total salpingectomy was done, and the excised right tube containing the mass was sent for histological examination, which revealed chorionic villi and hemorrhagic vascular decidual tissue in the fallopian tube, features suggestive of tubal ectopic pregnancy.

Spontaneous intrauterine pregnancy after tubal sterilization: A case report

The sterilization failure rate of a total bilateral salpingectomy is unknown. After a total bilateral salpingectomy, spontaneous intrauterine pregnancy is extremely rare; only four cases have been documented. This case report describes a 34-year-old G4P1213 with a history of bilateral salpingectomy who was found to have a viable intrauterine pregnancy. The pregnancy was continued and ended in a repeat cesarean section. At the time of surgery, a left tubal remnant was noted. While the patient was originally reported to have a complete salpingectomy, the evidence of a tubal stump makes this an unintended partial salpingectomy. It is theorized that dense pelvic adhesions at the time of the left salpingectomy increased the likelihood of sterilization failure. This is the first case report to evaluate the pelvic cavity after an intrauterine pregnancy following a reported complete bilateral salpingectomy. Patients should be counseled on the risk of ectopic and intrauterine pregnancy following a bilateral salpingectomy.

Permanent Contraception: Ethical Issues and Considerations: ACOG Committee Statement No. 8

Permanent contraception is the most used method of contraception among women aged 15-49 years and is one of the most straightforward surgical procedures an obstetrician-gynecologist can perform. At the same time, this therapeutic option is enormously complex when considered from a historical, sociological, or ethical perspective. This Committee Statement reviews ethical issues related to permanent contraception using a reproductive justice framework. Ethical counseling and shared decision making for permanent contraception should adopt a nonjudgmental, patient-centered approach, using up-to-date information about permanent contraception procedures and alternatives. Obstetrician-gynecologists should strive to avoid bringing into the clinical encounter biases around gender, race, age, and class that affect thoughts on who should or should not become a parent. Obstetrician-gynecologists should also ensure that permanent contraception requests reflect each patient's wishes, come from a desire to permanently end childbearing, and come from a preference for permanent contraception over all reversible methods as well as permanent contraception for the male partner. When difficulties in meeting a postpartum permanent contraception request are anticipated and permanent contraception is desired by the patient, transfer of care for the remainder of pregnancy should be offered. ACOG recognizes the right of all patients to unimpeded access to permanent contraception as a way of ensuring health equity, but it is unclear how to craft policies that protect from coercion but also do not create barriers to autonomously desired care. Determining the ethical balance between access and safeguards will require a collaborative interdisciplinary approach that involves a variety of stakeholders with varying perspectives.

Complete Compared With Partial Salpingectomy for Postpartum Sterilization

In this narrative review, we describe evidence regarding the associated risks, benefits, and cost effectiveness of postpartum complete salpingectomy compared with partial salpingectomy. Permanent contraception can be performed via several methods, but complete salpingectomy is becoming more common secondary to its coincident benefit of ovarian cancer risk reduction. Small prospective studies and larger retrospective cohort studies have demonstrated the feasibility and safety of complete salpingectomy in the postpartum period. Additionally, multiple cost-effectiveness analyses have demonstrated the cost effectiveness of this method secondary to ovarian cancer reduction over the life span. Although future larger cohort studies will allow for more precise estimates of the effect of complete salpingectomy on ovarian cancer risk and incidence of rare complications, current data suggest that complete salpingectomy should be offered to patients as a method of permanent contraception in the postpartum period.

Legal medicine aspects of female sterilization: our experience

Introduction

The most frequent sterilization procedures include postpartum tubal ligation, laparoscopic tubal disruption or salpingectomy, and hysteroscopic tubal occlusion. It may be performed via laparoscopy, mini-laparotomy, or hysteroscopy. Safety, efficacy, short-term complications, long-term complications, and non-contraceptive benefits of sterilization are different for each procedure. Female sterilization has become an important professional liability problem in obstetrics and gynecology.

Materials and methods

We analyzed 6 cases of surgical sterilization that have been the subject of civil proceedings. We review indications, contraindications, and complications associated with each sterilization procedure.

Results

In our small number of cases, women who have undergone sterilization performed negligently are entitled to recover damages for wrongful conception, negligence, and wrongful birth. We also consider the issue of female sterilization of minors.

Discussion

Tubal sterilization can be performed with different techniques, chosen in light of the various situations involved, with the goal of reducing as many as possible any failures. Thorough and complete communication of information is of primary importance.

Conclusion

Sterilization is the most widely used birth control method around the world. The procedure is generally safe and highly effective. As reported in the literature, the decision concerning method depends on the setting, the surgeon's experience, the country's economic development, and the woman's preference, but we think that some techniques present a greater risk of failure and expose the surgeon to malpractice litigation.

Postpartum Opportunistic Salpingectomy Compared With Bilateral Tubal Ligation After Vaginal Delivery for Ovarian Cancer Risk Reduction: A Cost-Effectiveness Analysis

OBJECTIVE

To compare the cost effectiveness of opportunistic salpingectomy and bilateral tubal ligation for sterilization immediately after vaginal delivery.

METHODS

A cost-effectiveness analytic decision model was used to compare opportunistic salpingectomy with bilateral tubal ligation during vaginal delivery admission. Probability and cost inputs were derived from local data and available literature. Salpingectomy was assumed to be performed with a handheld bipolar energy device. The primary outcome was the incremental cost-effectiveness ratio (ICER) in 2019 U.S. dollars per quality-adjusted life-year (QALY) at a cost-effectiveness threshold of $100,000/QALY. Sensitivity analyses were performed to determine the proportion of simulations in which salpingectomy would be cost effective.

RESULTS

Opportunistic salpingectomy was more cost effective than bilateral tubal ligation with an ICER of $26,150/QALY. In 10,000 patients desiring sterilization after vaginal delivery, opportunistic salpingectomy would result in 25 fewer ovarian cancer cases, 19 fewer ovarian cancer deaths, and 116 fewer unintended pregnancies than bilateral tubal ligation. In sensitivity analysis, salpingectomy was cost effective in 89.8% of simulations and cost saving in 13% of simulations.

CONCLUSION

In patients undergoing sterilization immediately after vaginal deliveries, opportunistic salpingectomy is more cost effective and may be more cost saving than bilateral tubal ligation for reducing ovarian cancer risk.

Efficacy of Tubal Surgery for Permanent Contraception: Considerations for the Clinician

Permanent contraception meets the needs of many people certain in their decision to never become pregnant in the future. Female permanent contraception procedures became more common than male procedures during the 1970s and 1980s, when laparoscopic surgery became widely available. To better understand the efficacy of these new procedures, the US Centers for Disease Control and Prevention conducted a prospective cohort study, known as the Collaborative Review of Sterilization (CREST). For decades, results of this study have defined perioperative counseling around failure risks of such surgeries. However, laparoscopic technology and techniques have changed significantly in recent decades and evidence has emerged supporting noncontraceptive benefits of tubal excision. Therefore, we present here a review of updated information regarding permanent contraception failure in the modern context and implications for clinical practice and future research directions.

Does socioeconomic factors and healthcare coverage affect postpartum sterilization uptake in an urban, tertiary hospital?

BACKGROUND

Postpartum sterilization in Thailand has relatively few barriers compared to other countries. The procedure is covered by some healthcare plans, and paid out-of-pocket for others. We aim to determine if healthcare coverage and other socioeconomic factors affect the rate of postpartum sterilization in an urban, tertiary hospital.

METHODS

We conducted a secondary analysis of data from a retrospective cohort of 4482 postpartum women who delivered at our hospital. Multivariable logistic regression was conducted to determine if sterilization reimbursement affects immediate postpartum sterilization rate.

RESULTS

Overall immediate postpartum sterilization rate was 17.8%. Route of delivery and parity were similar in those who were reimbursed and those who were not. Women aged over 25 were more likely to have a healthcare plan that does not cover postpartum sterilization. Women whose healthcare plan reimbursed the procedure trended towards postpartum sterilization when compared to women who were not (aOR 1.05, 95% CI 0.86-1.28, p-value = 0.632). Women who delivered via cesarean section were more likely to undergo sterilization at the time of delivery (aOR = 5.87; 95% CI 4.77-7.24, p-value = < 0.001). Women aged 40-44 years were 2.70 times as likely to choose sterilization than those aged 20-24 years (aOR = 2.70; 95% CI 1.61-4.53, p-value < 0.001).

CONCLUSIONS

Healthcare coverage of the procedure was not associated with increased postpartum sterilization in our setting.

The efficacy of postpartum tubal sterilization training program with minilaparotomy approach in Ob/Gyn residents

Objectives

To evaluate the efficacy of postpartum tubal sterilization training program with minilaparotomy approach (PTSMA).

Study design

From September 2020 to November 2021, 24 first-year Obstetrics and Gynecology (Ob/Gyn) residents were randomly allocated into 2 groups of traditional apprenticeship learning (watching video clip) versus apprenticeship learning plus PTSMA attending. The program consisted of didactics followed by self-practicing with 2 stations of postpartum tubal sterilization simulators (PTSS). All participants were allowed to perform their first tubal sterilization under supervision within a few days after training. Their surgical skills were blindly evaluated by 2 experts through the recorded videos. Five domains of direct observation of procedural skills (DOPS) score introduced by Royal Thai College of Obstetricians and Gynecologists were assessed. DOPS score, operative time, blood loss and post-op complication were analyzed and compared.

Results

Median of total DOPS score in the PTSMA group was higher than the non-PTSMA group (93 vs. 73, p = 0.020). Concerning 2 domains of DOPS score (tubal fishing and tubal sterilization), the PTSMA group had the higher median score than the non-PTSMA group (36 vs. 24, p = 0.045 and 40 vs. 32, p = 0.020). There was no significant difference observed in the median score of 3 other domains (peritoneal cavity accessing, abdominal wall closure and complication prevention), estimated blood loss and operative time.

Conclusion

Postpartum tubal sterilization training program with minilaparotomy approach using instructive simulators significantly improved the total DOPS score especially tubal fishing and tubal ligation skills in Ob/Gyn residents.

Implications

The study evidently showed the benefit of PTSMA with an inexpensive and simple to prepare models. In unexperienced operators, practicing in model prior to surgery should be encouraged to improve their operative skills.

Comparative Effectiveness and Safety of Intrauterine Contraception and Tubal Ligation

BACKGROUND

Tubal ligation remains common in the USA, especially among low-income patients.

OBJECTIVE

To compare the effectiveness and safety of intrauterine contraceptives (IUC) to laparoscopic tubal ligation for Medicaid clients.

DESIGN

We partnered with patient and clinician stakeholders to conduct a retrospective cohort study using California Medicaid claims for patients who had an IUC placed or laparoscopic tubal ligation performed in 2008-2014, excluding procedures performed within 42 days of a birth. We applied log-linear (Poisson) event-history regression models for clustered person-period data to adjust for sociodemographic variables and pre-procedure health status when examining associations between these contraceptive procedures and claims related to contraceptive failure, complications, and pain in the first year post-procedure.

KEY RESULTS

We identified 35,705 patients who had a levonorgestrel IUC placed, 23,628 patients who had a copper IUC placed, and 23,965 patients who underwent laparoscopic tubal ligation. In unadjusted analyses, rates of pregnancy within 1 year were similar following levonorgestrel IUC (2.40%) or copper IUC placement (2.99%) or tubal ligation (2.64%). In adjusted analyses, compared to tubal ligation, pregnancy was less common following placement of a levonorgestrel IUC (adj IRR 0.72, 95% CI 0.64-0.82) and similar with placement of a copper IUC (adj IRR 0.92, 95% CI 0.82-1.05). Procedural complications such as infection (0.35% vs. 2.91%) were significantly less common with IUC placement than tubal ligation. Claims for pelvic and abdominal pain decreased in frequency with time since all procedures; 6 to 12 months post-procedure, pelvic pain claims were less common after levonorgestrel IUC (adj IRR 0.69, 95% CI 0.65-0.73) or copper IUC placement (adj IRR 0.70, 95% CI 0.66-0.75) than tubal ligation.

CONCLUSIONS

IUC appears at least as effective as laparoscopic tubal ligation at 1-year post-procedure with lower rates of infection and pelvic pain 6 to 12 months post-procedure.

CLINICAL TRIAL REGISTRATION

NCT03438682.

Salpingectomy, tubal ligation and hysteroscopic occlusion for sterilization

INTRODUCTION

Sterilization of females is considered one of the most prevalent contraceptive techniques among women in the United States. There are many surgical sterilization procedures including salpingectomy, tubal ligation, and hysteroscopic occlusion of the fallopian tubes. We provide an overview of these methods from the clinical data and latest studies available on this topic.

EVIDENCE ACQUISITION

In order to review the latest literature on the topic, we searched electronic databases including PubMed, Web of Science, Scopus, and Cochrane library for all eligible studies from May 1st 2018 until May 1st 2022 using the following strategy: ("fallopian tube removal" OR Salpingectomy OR "fallopian tube excision" OR "tubal sterilization") AND ("tubal ligation" OR "bipolar coagulation" OR "tubal clip" OR "tubal ring" OR fimbriectomy). We reviewed every study that met our criteria and subjectively considered their results and methodology into this narrative review.

EVIDENCE SYNTHESIS

In addition to reviewing major guidelines in the United States, 19 recent studies met our eligibility criteria and were included in this review. We grouped the findings under the following headings: anatomical and physiological considerations, sterilization, salpingectomy, tubal ligation, and hysteroscopic tubal occlusion.

CONCLUSIONS

Bilateral salpingectomy and techniques of tubal ligation or occlusion continue to be effective procedures with good safety profiles. All techniques have similar surgical outcomes and long-term success rates. As salpingectomy has the advantage of reducing the risk of occurrence of ovarian cancer, this is preferential when feasible. Hysteroscopic occlusion techniques may be more minimally invasive but have the disadvantages of delayed efficacy, the need for a second invasive diagnostic procedure, and limited availability.

Applicability, Safety, and Efficiency of Salpingectomy versus Electrocoagulation and Laparoscopic Tubal Section in Ambulatory

OBJECTIVE

 Female sterilization is a surgical procedure that aims women to permanently stop the use of conception. The benefits, risks and cost-effectiveness are important issues. The purpose of this study was comparing the applicability, complications and efficacy of salpingectomy versus electrocoagulation and tubal occlusion by laparoscopy in the Ambulatory Surgery Unit.

METHODS

 We performed a retrospective and observational study that included women undergoing laparoscopic sterilization procedures at our Ambulatory Surgery Unit, during three years. Statistical analysis was performed using SPSS, applying the Fisher exact test, the Mann-Whitney test, and Linear Regression.

RESULTS

 Two hundred and twenty-one laparoscopic surgical procedures were performed, including 79 (35.7%) bilateral total salpingectomies and 142 (64.3%) electrocoagulation and bilateral tubal occlusion procedures. The majority of the procedures were performed by a resident (n = 162; 73.3%), with 40% (n = 33) of salpingectomies. The surgical time, independently the type of surgeon, was significantly shorter in the tubal occlusion (42.2 vs. 52.7 min, p < 0.001). Safety and efficacy endpoints were not significantly different between the two groups, with a case of pregnancy in tubal occlusion group.

CONCLUSION

 Salpingectomy is a safe and effective alternative comparing with electrocoagulation and tubal occlusion.

Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study

OBJECTIVE

To compare real-world effectiveness of hysteroscopic to laparoscopic sterilization.

DESIGN

Retrospective cohort of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical variables to examine the poststerilization pregnancy rates.

SETTING

Clinics, hospitals.

PATIENT(S)

Women aged 18-50 years with Medicaid claims between January 1, 2008, and August 31, 2014.

INTERVENTION(S)

Hysteroscopic or laparoscopic sterilization procedure.

MAIN OUTCOME MEASURE(S)

Poststerilization pregnancy measured by pregnancy-related claims.

RESULT(S)

Among women with hysteroscopic (n = 5,906) or laparoscopic (n = 23,965) sterilization, poststerilization pregnancy claims were identified for 4.74% of women after hysteroscopic sterilization and 5.57% after laparoscopic sterilization. The pregnancy rates decreased over time after either procedure. Twelve months after the procedure, the crude incidence of pregnancy claims was higher for hysteroscopic sterilization than for laparoscopic sterilization (3.26 vs. 2.61 per 100 woman-years), but the propensity-weighted adjusted incidence rate ratio was 1.06 (95% confidence interval [CI], 0.85-1.26). Between 13 and 24 months after the procedure, there were fewer pregnancies for women after hysteroscopic sterilizations than for those after laparoscopic sterilizations (adjusted incidence rate ratio, 0.63 [95% CI, 0.45-0.88]), with no statistically significant differences in later years. The cumulative pregnancy rates 5 years after sterilization were lower with hysteroscopic sterilization than with laparoscopic sterilization (6.26 vs. 7.22 per 100 woman-years; propensity-weighted, adjusted risk ratio, 0.76 [95% CI, 0.62-0.90]). The poststerilization pregnancy rates varied by age and race/ethnicity.

CONCLUSION(S)

The pregnancy rates after female sterilization are higher than expected, whether performed hysteroscopically or laparoscopically. These findings are reassuring that the effectiveness of hysteroscopic sterilization was not inferior to laparoscopic sterilization.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03438682.

[Vaginal tubal sterilization: About a series of 158 patients from 2005 to 2021]

OBJECTIVES

The latest recommendations of 2006 on tubal sterilization reported an infectious risk of 1.5 to 2.5% for the vaginal approach. There is, however, limited literature on this approach. The primary objective of our study was to investigate the feasibility of tubal sterilization via posterior colpotomy. The secondary objectives were to study the reproducibility of this approach, the postoperative infection rate after tubal sterilization via posterior colpotomy, to evaluate its peroperative and postoperative morbidity.

METHODS

This retrospective study, conducted at the Antibes's Hospital, included patients over 18 years of age who underwent tubal ligation with clips or bilateral vaginal salpingectomy from 2005 to 2021.

RESULTS

We included a total of 158 patients: 88% by clips and 12% by bilateral salpingectomy. The average operative duration was of 27 minutes. There were no infectious or postoperative complications directly related to the sterilization. There were two failures of the technique, requiring conversion to laparoscopy (1.3%) and four subsequent pregnancies (2.5%).

CONCLUSIONS

We were able to show low morbidity and failure rates with this surgical technique. It, therefore, does not appear to be inferior to the laparoscopic approach. Moreover, it is reproducible technique.

Investigating Barriers to Completion of Postpartum Tubal Ligation: A Retrospective Chart Review

OBJECTIVES

To identify the completion rate for postpartum tubal ligation (PPTL) and predictors of noncompletion of PPTL in a central New Jersey population.

METHODS

We conducted a retrospective chart review at a tertiary care center in New Jersey for patients delivering during an 18-month period. We used the electronic medical record to identify all of the patients who had documented desire for a PPTL at the time of admission. We calculated the rate of PPTL completion and identified predictors of completion and risk factors for noncompletion. We recorded any documented reasons for cancellation and choice of contraception after noncompletion.

RESULTS

Of 626 women who requested PPTL on admission, 508 (81.2%) procedures were performed. The most common reasons for noncompletion were patient changing her mind (38.1%) and unknown/not documented (22.9%). Cesarean delivery was the strongest predictor of completion, with 93.4% completion among cesarean deliveries compared with 65.6% among vaginal deliveries (P < 0.01). Lack of insurance also was associated with noncompletion (P < 0.01). There was no difference in body mass index (P = 0.75), gravidity (P = 0.99), parity (P = 0.72), or high-risk status (P = 0.47) between completed and noncompleted PPTL.

CONCLUSIONS

Cesarean delivery is a strong predictor of PPTL completion, most likely because of easier availability of the operating room, anesthesia, and ancillary staff. Body mass index, gravidity, and parity are not associated with PPTL completion. Future research should focus on exploring whether this association is system, provider, or patient dependent.

Conventional Laparoscopy Is the Better Option for Tubal Sterilization Reversal: A Closer Look at Tubal Reanastomosis

Background: Permanent sterilization is one of the most common methods of birth control in the United States and around the world. A small subset of women will regret their decision and desire future fertility. For these women, the options include in vitro fertilization (IVF) or surgical reversal. Surgical reversal, specifically via tubal reanastamosis, is an important choice to consider. Surgical reversal can be accomplished via three different general approaches including laparotomy, conventional laparoscopy, and robot-assisted approaches. Unfortunately, surgical reversal is becoming a lost art.

Objective: To compare and contrast pregnancy success rates, ectopic pregnancy rates, and cost between the surgical methods and IVF.

Methods: We conducted a literature review via Pubmed with keywords as listed below.

Conclusion: Laparoscopic tubal reanastomosis is the best approach for women <40 years of age due to pregnancy outcomes that are comparable to other methods, cost effectiveness, and favorable safety profile of minimally invasive surgery.

Paradigm shift from tubal ligation to opportunistic salpingectomy at cesarean delivery in the United States

BACKGROUND

Opportunistic salpingectomy is now recommended at the time of routine gynecologic surgery to reduce the risk of future ovarian cancer, and performance of opportunistic salpingectomy has increased markedly at the time of benign hysterectomy. Salpingectomy has also been suggested to be feasible at the time of cesarean delivery in women desiring sterilization; however, uptake has not been previously studied on a national level.

OBJECTIVE

This study aimed to examine recent population trends in the utilization and characteristics of salpingectomy at the time of cesarean delivery in the United States.

STUDY DESIGN

This is a population-based retrospective observational study querying the National Inpatient Sample between October 2015 and December 2018. The primary outcome measure was the temporal trend of bilateral salpingectomy at cesarean delivery, assessed with linear segmented regression with log transformation utilizing 3-month time increments. The secondary outcome measures included patient characteristics associated with bilateral salpingectomy, assessed with a multinomial regression model, and surgical outcome (hemorrhage, blood transfusion, hysterectomy, and oophorectomy) at the time of bilateral salpingectomy vs bilateral tubal ligation, assessed with generalized estimating equation in a propensity score-matched model.

RESULTS

There were 3,813,823 women at the age of 15 to 49 years who had cesarean deliveries included, of whom 397,260 (10.4%) had bilateral salpingectomy and 203,400 (5.3%) had bilateral tubal ligation overall. During the time period studied, performance of bilateral salpingectomy among women undergoing cesarean delivery significantly increased from 4.6% to 13.2% (odds ratio for the fourth quarter of 2018 vs the fourth quarter of 2015, 2.69; 95% confidence interval, 2.63-2.75; Figure panel). In contrast, performance of bilateral tubal ligation among women undergoing cesarean delivery significantly decreased from 11.3% to 2.4% (odds ratio, 0.20; 95% confidence interval, 0.19-0.21). By the third quarter of 2016, the number of women who had bilateral salpingectomy exceeded those who had bilateral tubal ligation at cesarean delivery (8.6% vs 7.3%). Increasing the utilization of bilateral salpingectomy did not vary across age groups; the salpingectomy rate increased from 7.5% to 21.1% among women at the age of ≥35 years and from 3.8% to 10.7% among women at the age of <35 years (both, P<.001). In a propensity score matched model, women in the bilateral salpingectomy group were more likely to have hemorrhage (3.8% vs 3.1%; odds ratio, 1.24; 95% confidence interval, 1.15-1.33), blood product transfusion (2.1% vs 1.8%; odds ratio, 1.16; 95% confidence interval, 1.04-1.30), hysterectomy (0.8% vs 0.4%; odds ratio, 2.28; 95% confidence interval, 1.84-2.82), and oophorectomy (0.3% vs 0.2%; odds ratio, 2.02; 95% confidence interval, 1.47-2.79) than those in the bilateral tubal ligation group. When restricted to the nonhysterectomy cases, the bilateral salpingectomy group had a higher rate of hemorrhage (3.4% vs 3.0%; odds ratio, 1.16; 95% confidence interval, 1.06-1.26) and oophorectomy (0.3% vs 0.1%; odds ratio, 1.75; 95% confidence interval, 1.22-2.50) than the bilateral tubal ligation group.

CONCLUSION

In the United States, the utilization of bilateral salpingectomy at the time of cesarean delivery increased rapidly between 2015 and 2018, replacing tubal ligation as the most common type of sterilization performed with cesarean delivery. The higher surgical morbidity in the bilateral salpingectomy group than the bilateral tubal ligation group observed in this study warrants further investigation.

Spontaneous Pregnancy after Total Bilateral Salpingectomy: A Systematic Review of Literature

OBJECTIVE

To assess the occurrence of spontaneous pregnancy after a history of total bilateral salpingectomy (BS).

DATA SOURCES

A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, searching MEDLINE, Embase, Google Scholar, PubMed, SCOPUS, and Web of Science from database inception to February 20, 2020.

METHODS OF STUDY SELECTION

We included women with a history of total BS for any indication with subsequent spontaneous pregnancy. Excluded were women who had a history of incomplete/partial salpingectomy or tubal occlusion, who had pregnancy after assisted reproductive technology, and whose pregnancy was not appropriately confirmed via beta-subunit of human chorionic gonadotropin or ultrasound.

TABULATION, INTEGRATION, AND RESULTS

The systematic search retrieved 1942 articles; 39 studies were potentially eligible, and their full texts were reviewed. A total of 4 case reports were included. Total BS had been performed for other indications than permanent contraception in all cases. Pain was the most common presenting symptom. All 4 pregnancies were intrauterine in location. Treatment was based on desire to continue pregnancy and hemodynamic stability.

CONCLUSION

Spontaneous pregnancy after total BS is exceedingly rare. The present data suggest that it is reassuring to offer total BS as a form of permanent contraception. Prospective data are warranted to ascertain short- and long-term effects of total BS for permanent contraception including its efficacy.

Long-Term Failure Rates of Interval Filshie Clips As a Method of Permanent Contraception

Background: In 1996, the U.S. Collaborative Review of Sterilization (CREST) reported permanent contraception failure rates by method, but did not include the Filshie clip. Subsequent research provides data for Filshie clip failure rates up to 24 months, but rigorously designed and executed studies examining failure rates beyond 2 years are lacking. Objectives: To describe non-Filshie and Filshie procedures, identify failures, and calculate 10-year pregnancy rates among patients who have undergone interval permanent contraception procedures with Filshie clips. Study Design: We performed chart review for patients who underwent interval permanent contraception procedures between 2000 and 2014 at our institution. We identified births after permanent contraception by utilizing both chart review and the Utah Population Database. We report results from life table analysis, with censoring at failure, 49 years of age, or last observed date of service. Results: In this cohort of 693 patients, surgeons most commonly used Filshie clips for interval permanent contraception (N = 547, 78.8%). We classified pregnancies after Filshie clip procedures as verified (n = 4) or self-reported (n = 3). We obtained 5 years of data for 411 patients (59.3% of all permanent contraception procedures), and more than 10 years of data for 257 patients (37.1%). We calculated a cumulative 5- and 10-year pregnancy rate to be the same, including both verified and self-reported pregnancies, of 9.8 (95% confidence interval [CI] 4.1-23.3)/1000 women using Filshie clips. The 10-year rate of verified pregnancy is 2.8 (95% CI 1.0-15.7)/1000 women. Conclusion: Overall, long-term failure of Filshie clip interval permanent contraception procedures is infrequent, with a 10-year cumulative probability of failure of 4.1-23.3/1000 procedures performed. Filshie clips compare favorably with other methods of permanent contraception included in the CREST study, where the 10-year cumulative probability of failure ranged from 7.5 to 36.5/1000 procedures performed.

Removing Unnecessary Medical Barriers to Contraception: Celebrating a Decade of the U.S. Medical Eligibility Criteria for Contraceptive Use

In 2010, the Centers for Disease Control and Prevention (CDC) released the U.S. Medical Eligibility Criteria for Contraceptive Use, providing recommendations for health care providers on safe use of contraception for people with certain characteristics or medical conditions. Adapted from World Health Organization guidance, the goal of the recommendations is to remove unnecessary medical barriers to contraception. Over the past decade, CDC has updated recommendations based on new evidence, collaborated with national partners to disseminate and implement the guidelines, and conducted provider surveys to assess changes in attitudes and practices around contraception safety and provision. CDC remains committed to supporting evidence-based guidelines for safe use of contraception, as the basis for improving access to contraception and high-quality family planning services, reducing unintended pregnancy, and improving reproductive health in the United States.

Examining the Association of Obesity With Postpartum Tubal Ligation

OBJECTIVE

To evaluate the association of increasing body mass index (BMI) on postpartum tubal ligation safety and estimate the rates of procedure complication.

METHODS

We conducted a single-institution, retrospective review. Women undergoing postpartum permanent contraception after vaginal delivery from August 2015 to March 2019 were studied. Our primary outcome included a composite morbidity of intraoperative complications (bleeding requiring additional surgery, and extension of incision), blood transfusion, aborted procedure, anesthetic complication, readmission, wound infection, venous thromboembolism, ileus or small bowel obstruction, incomplete transection, and subsequent pregnancy. Statistical analysis included t test, χ test, and Wilcoxon rank-sum test, with P<0.05 considered significant.

RESULTS

During the study period, 3,670 women were studied: 263 were underweight or normal weight (BMI 24.9 or lower), 1,044 were overweight (25-29.9), 1,371 had class I obesity (30-34.9), 689 had class II obesity (35-39.9), and 303 had class III obesity (40 or higher) at the time of admission. Composite morbidity occurred in 49 cases (1.3%) and was not significantly different across the BMI categories (P=.07). Twelve cases of incomplete transection were noted on pathology reports; however, none of these accounted for the six subsequent pregnancies that were identified. There were no deaths or events leading to death noted in the study population. The length of time to complete the procedure increased across BMI categories (23 minutes in women with normal weight, and 31 in women with class III obesity) (P<.001).

CONCLUSION

There was no association between increased BMI and morbidity with women undergoing postpartum tubal ligation. Postpartum tubal ligation should be considered a safe and reasonable option for women, regardless of BMI.

The process of opting for female permanent contraception: A qualitative study of women's experiences in Sweden

OBJECTIVES

We aimed to explore Swedish women's decision-making experiences regarding permanent contraception.

STUDY DESIGN

In this study, we included 17 women aged 30-48 who were scheduled to undergo female permanent contraceptive procedures. We conducted semistructured interviews using two broad open-ended questions. We analyzed these data using systematic text condensation based on the principles of psychological phenomenological analysis.

RESULTS

The interviewees experienced no counseling or support from health care workers regarding permanent contraception until they specifically asked for it. Participants reported that they themselves place the responsibility of permanent contraception solely on women. Consequently, our participants described feeling hesitancy and ambivalence in the process of deciding to have the procedure. Once the decision was made and the women were on the waiting lists for surgery, they experienced relief and empowerment.

CONCLUSIONS

Our findings suggest that health care providers in Sweden miss opportunities to support patient-centered decision-making regarding permanent contraception. This study indicates that women make deliberate and considered decisions regarding permanent contraception and are best positioned to know when the procedure should take place in their reproductive lives.

IMPLICATION STATEMENTS

Health care professionals should discuss permanent contraception as an option with all women desiring contraception to allow them to decide if that method is right for them.

Pregnancy and Congenital Heart Disease: A Brief Review of Risk Assessment and Management

Cardiac disease is a leading cause of morbidity and mortality in pregnant women. An increased prevalence of the cardiovascular disease has been found in women of childbearing age, in which the responsibility of the treating physician extends to the mother and to the unborn fetus. As a result, care of these high-risk pregnant women with cardiovascular disease including those with congenital heart disease (CHD) require a team approach including specialists in maternal-fetal medicine, adult congenital cardiology, and obstetrical anesthesia. The human body undergoes significant amounts of physiological changes during this period of time and the underlying cardiac disease can affect both the mother and the fetus. Today, most female children born with CHD will reach childbearing age. For many women with complex CHD, carrying a pregnancy has a moderate to high risk for both the mother and her fetus. This chapter will review the epidemiology, risk factors, clinical presentation including common signs and symptoms, physiological changes in pregnancy, and the medical approach including cardiac medications, percutaneous interventions, and surgical procedures for pregnant women with CHD.

Bring back the tubal: An intervention to provide postpartum tubal ligation in the underserved population

We aimed to improve educational awareness of postpartum bilateral tubal ligation (PPBTL), which we defined as a 15% improvement between pre-/post-intervention questionnaire scores. We followed patients desiring and undergoing PPBTL and reason for unfulfilled procedures from 2017-2018. OB/GYN, Nursing, and Anesthesia participated in educational sessions with pre-/post-intervention questionnaires. Comparing the first and latter six months after study initiation, PPBTLs performed increased from 39% to 54%. Fifty-two staff participated in the interventions, with a 21% improvement in scores (OB/GYN p = 0.0117, Nursing p = 0.0001, Anesthesia p = 0.0002). We conclude multidisciplinary interventions improved educational awareness, an integral part to increasing PPBTL performance in the underserved.

Patients' perceptions toward and the driving factors of decision-making for opportunistic bilateral salpingectomy at the time of cesarean section

Objective:

Enough data can be found in the literature regarding the protective effect of tubal ligation on gynecological cancers. In addition, a large body of evidence revealed that prophylactic bilateral salpingectomy had no significant negative effect on the ovarian function, quality of life, sexuality, surgery duration, and cost-effectivity. This study was aimed at exploring the underlying factors that motivate women for either opportunistic bilateral salpingectomy (OBS) or tubal ligation, particularly focusing on their preferences, knowledge, and beliefs toward female sterilization, satisfaction from counseling, and body image following the salpingectomy.

Materials and Methods:

A total of 54 patients who had undergone surgical sterilization with either OBS or tubal ligation were included in this prospective cohort study. The acceptance rate of the OBS at the time of cesarean section among pregnant women seeking surgical sterilization was calculated. The underlying reasons for women’s acceptance or refusal for salpingectomy were assessed by a non-validated data collection tool that had 14 open-ended questions focusing on the women’s preferences, knowledge, beliefs toward female sterilization, satisfaction from counseling, and body image following the salpingectomy.

Results:

The acceptance rate of OBS at the time of cesarean section among pregnant women and electively among non-pregnant women were 93.5% (n=43/46) and 75% (6/8), respectively. The main driving factors influencing the decision of preferring OBS over tubal ligation were the risk-reducing effect for ovarian cancer and superior pregnancy prevention.

Conclusion:

The acceptance rate of OBS at the time of cesarean section was found to be very high, and it should therefore be offered at the time of cesarean section to women who desire permanent contraception.

Using Deliberative and Qualitative Methods to Recommend Revisions to the Medicaid Sterilization Waiting Period

BACKGROUND

Sterilization is used by one-quarter of women in the United States for contraception and is a preferred birth control method among women with Medicaid. A history of coercive sterilization practices in the United States led to federal regulation of consent for Medicaid sterilization (including a mandated waiting period); this regulation can be a barrier to sterilization in Medicaid-insured women. This study aimed to develop a revised model of Medicaid sterilization policy grounded in the experiences of women impacted by current regulations.

METHODS

This prospective study used in-depth interviews with 32 Medicaid-insured women who had obtained or tried to obtain sterilization to elicit recommendations regarding the Medicaid waiting period. Deliberative methods (a planning cell including 20 key community stakeholders) were used to evaluate women's recommendations and propose a revised policy for sterilization under Medicaid.

RESULTS

In-depth interview data demonstrated that women were often not made aware of the 30-day waiting period during informed consent before sterilization. Once informed about the policy, women described the Medicaid waiting period as "unfair," because it did not apply to all women. After deliberating women's recommendations to change the policy, key stakeholders came to a consensus around replacing the current waiting period policy with an improved consent process that would acknowledge the problematic history of coercive sterilization. Participants could not endorse removing the waiting period altogether without evidence that the health system had shifted away from coercive sterilization practices.

CONCLUSIONS

Using deliberative methods and the recommendations of women with Medicaid insurance, community stakeholders recommended developing a revised Medicaid sterilization consent policy that acknowledged the historical context of this procedure.

Salpingectomie bilatérale aux fins de contraception permanente : série de cas et facteurs limitant le changement de pratique

OBJECTIVE

The Society of Obstetricians and Gynaecologists of Canada (SOGC) and the Society of Gynaecologic Oncology of Canada (GOC) recommend complete removal of the fallopian tubes as a permanent contraceptive method because of its association with a reduced risk of ovarian cancer. Currently, many women are not offered bilateral salpingectomy as an alternative to tubal ligation for permanent contraception.

METHOD

As part of a quality improvement initiative, we reviewed all cases of sterilization performed at our university centre between 1 January and 31 December 2018. A literature review of the clinical and ethical considerations that prevent clinicians from offering bilateral salpingectomy as permanent contraception is also presented.

RESULTS

The records of 111 women who underwent tubal sterilization were reviewed. Of these, 31.5% underwent bilateral salpingectomy; 46.8% underwent tubal fulguration; 12.6% underwent clip ligation; and 9.1% underwent tubal implant ligation (Essure). According to the information on file, only 36.3% of women were offered bilateral salpingectomy, and of these, 83.8% chose this method.

CONCLUSION

Bilateral salpingectomy should be offered to all women seeking permanent contraception. The benefits and very low risks associated with this procedure should make it a first choice option.

Knowledge, attitudes, and perceptions of antenatal women to postpartum bilateral tubal ligation at Greys Hospital, KwaZulu-Natal, South Africa

OBJECTIVES

To evaluate the associations between socio-demographic factors and the general knowledge, the attitudes and perceptions of women attending antenatal clinic at Greys Hospital regarding postpartum tubal ligation (BTL).

METHODS

A prospective cross-sectional study describing the perceptions about BTL in 241 pregnant women was conducted.

RESULTS

One hundred and sixty six (68.9%) participants needed to involve their partners before tubal ligation. Thirty five percent of 102 participants who would not have BTL against partner's wish were unemployed. Eighty three (34.4%) participants, mostly with secondary and tertiary education believed that successful reversal of BTL is guaranteed. Fifty two percent of participants, predominantly with no formal schooling and primary education levels were unaware of the risk of falling pregnant after BTL. Sixty seven (27.8%) participants, predominantly with primary education or no formal schooling believed that BTL protects against STIs and HIV. Seventy eight (32.4%) of participants would not have BTL due to religious beliefs, however, participants from the same religion gave different answers to the question.

CONCLUSION

The study showed a significant lack of knowledge on key points of BTL. Socio-demographic factors still influence this subject and should not be underestimated during counselling of the patients to reduce potential morbidity and litigation.

Relationship between body mass index and operative time in women receiving immediate postpartum tubal ligation

OBJECTIVES

The aim of the study was to (1) assess the relationship between body mass index (BMI) and operative time during immediate postpartum tubal ligation procedures and to (2) determine whether operative time is non-inferior in women with BMI ≥30 versus women with BMI <30 and in women with BMI ≥40 versus women with BMI <40.

STUDY DESIGN

We conducted a retrospective cohort study of women who received immediate postpartum tubal ligations following vaginal delivery from 2013 to 2017 at a university hospital. We abstracted demographic information, patient and procedural characteristics, and clinical outcomes. We assessed the relationship between BMI and operative time via linear regression. We also conducted non-inferiority analysis to determine whether the mean operative time in women with BMI ≥30 was non-inferior to the mean operative time in women with BMI <30, within a non-inferiority margin of 10 min. We compared intraoperative and postoperative complications in the two groups.

RESULTS

A total of 279 women were included for analysis, among whom N=79 (28%) had a BMI of 25-29.9 and N=171 (61%) had a BMI ≥30. Demographic characteristics were similar in both groups. We found that operative time increased by 35 s for each one-point increase in BMI (p<.01). Although mean operative time was 46.1 min (n=171; 95% CI 43.7, 48.6 min) for women with BMI ≥30 and 40.6 min (n=108; 95% CI 37.9 min, 43.4 min) for women with BMI <30, (p<.01), it was non-inferior within a 10-min margin. There was no difference in rates of intraoperative or postoperative complications, incision length, total anesthesia time, and median length of stay between women with BMI ≥30 and BMI <30.

CONCLUSION

There is a small increase in postpartum tubal ligation operative time with increasing BMI. However, among women who received immediate postpartum tubal ligations at our institution, women with BMI ≥30 versus BMI <30 had operative times that were non-inferior within a 10-min margin.

IMPLICATIONS

While increasing body mass index slightly increases the operative time for immediate postpartum tubal ligations, this increase in time does not appear to be clinically significant.

Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery

BACKGROUND

Removal of the fallopian tubes at the time of hysterectomy or interval sterilization has become routine practice to prevent ovarian cancer. While emerging as a strategy, uptake of this procedure at the time of cesarean delivery for pregnant women seeking permanent sterilization has not been widely adopted due to perceptions of increased morbidity and operative difficulty with a lack of available data in this setting.

OBJECTIVE

We sought to conduct a cost-effectiveness analysis comparing strategies for long-term sterilization and ovarian cancer risk reduction at the time of cesarean delivery, including bilateral tubal ligation, opportunistic salpingectomy, and long-acting reversible contraception.

STUDY DESIGN

A decision-analytic and cost-effectiveness model was constructed for pregnant women undergoing cesarean delivery who desired permanent sterilization in the US population, comparing 3 strategies: (1) bilateral tubal ligation, (2) bilateral opportunistic salpingectomy, and (3) postpartum long-acting reversible contraception. This theoretic cohort consisted of 110,000 pregnant women desiring permanent sterilization at the time of cesarean delivery and ovarian cancer prevention at an average of 35 years who were monitored for an additional 40 years based on an average US female life expectancy of 75 years. The primary outcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured as quality-adjusted life years. Secondary outcomes included: the number of ovarian cancer cases and deaths, procedure-related complications, and unintended and ectopic pregnancies. The 1-, 2-, and 3-way and Monte Carlo probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set at $100,000.

RESULTS

Both bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery have favorable cost-effectiveness ratios. In the base case analysis, salpingectomy was more cost-effective with an incremental cost-effectiveness ratio of $23,189 per quality-adjusted life year compared to tubal ligation. Long-acting reversible contraception after cesarean was not cost-effective (ie, dominated). Although salpingectomy and tubal ligation were both cost-effective over a wide range of cost and risk estimates, the incremental cost-effectiveness ratio analysis was highly sensitive to the uncertainty around the estimates of salpingectomy cancer risk reduction, risk of perioperative complications, and cost. Monte Carlo probabilistic sensitivity analysis estimated that tubal ligation had a 49% chance of being the preferred strategy over salpingectomy. If the true salpingectomy risk of perioperative complications is >2% higher than tubal ligation or if the cancer risk reduction of salpingectomy is <52%, then tubal ligation is the preferred, more cost-effective strategy.

CONCLUSION

Bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery are both cost-effective strategies for permanent sterilization and ovarian cancer risk reduction. Although salpingectomy and tubal ligation are both reasonable strategies for cesarean patients seeking permanent sterilization and cancer risk reduction, threshold analyses indicate that the risks and benefits of salpingectomy with cesarean delivery need to be better defined before a preferred strategy can be determined.

An uncommon spontaneous right distal tubal pregnancy post bilateral laparoscopic sterilization: A case report

RATIONALE

Tubal sterilization as a contraception method has a high success rate; however, it also carries a low risk of incidental pregnancy. A majority of these pregnancies are ectopic. In this study, we report a rare case of spontaneous right distal tubal pregnancy after bilateral laparoscopic tubal sterilization.

PATIENT CONCERNS

A 36-year-old woman who had undergone bilateral laparoscopic tubal sterilization presented with abdominal pain and a positive test for pregnancy.

DIAGNOSIS

Ectopic pregnancy was suspected based on absence of gestational sac in the uterine cavity on ultrasound and elevated beta-human chorionic gonadotropin (β-hCG) level.

INTERVENTION

Since the patient had unstable vitals, emergency laparoscopic surgery was performed, which revealed a right distal fallopian tube pregnancy. We performed a complete bilateral residual tubal stump excision.

OUTCOMES

The patient recovered well after surgery, with a reduction in β-hCG level, and was discharged after 3 days.

LESSONS

To ensure complete sterilization, the gap at the excised end needs to be adequately widened and enhanced with electro-destruction to prevent formation of a fistula.

The cost-effectiveness of opportunistic salpingectomy versus standard tubal ligation at the time of cesarean delivery for ovarian cancer risk reduction

OBJECTIVES

Opportunistic salpingectomy is a cost-effective strategy recommended for ovarian cancer (OvCa) risk reduction at the time of gynecologic surgery in women who have completed childbearing. We aimed to evaluate the cost-effectiveness of opportunistic salpingectomy compared to standard tubal ligation (TL) during cesarean delivery.

STUDY DESIGN

A cost-effectiveness analysis using decision modeling to compare opportunistic salpingectomy to TL at the time of cesarean using probabilities of procedure completion derived from a trial. Probability and cost inputs were derived from local data and the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER) in 2017 U.S. dollars per quality-adjusted life year (QALY) at a cost-effectiveness threshold of $100,000/QALY. One- and two-way sensitivity analyses were performed for all variables. A probabilistic sensitivity analysis determined the proportion of simulations in which each strategy would be cost-effective.

RESULTS

Opportunistic salpingectomy was cost-effective compared to TL with an ICER of $26,616 per QALY. In 10,000 women desiring sterilization with cesarean, opportunistic salpingectomy would result in 17 fewer OvCa diagnoses, 13 fewer OvCa deaths, and 25 fewer unintended pregnancies compared to TL - with an associated cost increase of $4.7 million. The model was sensitive only to OvCa risk reduction from salpingectomy and TL. Opportunistic salpingectomy was not cost-effective if its cost was >$3163.74 more than TL, if the risk-reduction of salpingectomy was <41%, or if the risk-reduction of TL was >46%. In probabilistic sensitivity analysis opportunistic salpingectomy was cost effective in 75% of simulations.

CONCLUSIONS

In women undergoing cesarean with sterilization, opportunistic salpingectomy is likely cost-effective and may be cost-saving in comparison to TL for OvCa risk reduction.

Top-cited articles in the Journal: a bibliometric analysis

BACKGROUND

The Journal has had a profound influence in nearly 150 years of publishing. A bibliometric analysis, which uses citation analyses to evaluate the impact of articles, can be used to identify the most impactful papers in the Journal's history.

OBJECTIVE

The objective was to identify and characterize the top-cited articles published in the Journal since 1920.

STUDY DESIGN

We used the Web of Science and Scopus databases to identify the most frequently cited articles of the Journal from 1920 through 2018. The top 100 articles from each database were included in our analysis. Articles were evaluated for several characteristics including year of publication, article type, topic, open access, and country of origin. Using the Scopus data, we performed an unadjusted categorical analysis to characterize the articles and a 2 time point analysis to compare articles before and after 1995, the median year of publication from each database list.

RESULTS

The top 100 articles from each database were included in the analysis. This included 120 total articles: 80 articles listed in both and 20 unique in each database. More than half (52%) were observational studies, 9% were RCTs, and 75% were from US authors. When the post-1995 studies were compared with the articles published before 1995, articles were more frequently cited (median 27 vs 13 citations per year, P < .001), more likely to be randomized (14.0% vs 4.8%, P = .009), and more likely to originate from international authors (33.3% vs 17.5%, P = .045).

CONCLUSION

Slightly more than half of the top-cited papers in the Journal since 1920 were observational studies and three quarters of all papers were from US authors. Compared with top-cited papers before 1995, the Journal's top-cited papers after 1995 were more likely to be randomized and to originate from international authors.

Effect of contraceptive choice on rapid repeat pregnancy

OBJECTIVE

To describe the prevalence of rapid repeat pregnancy (RRP), defined as repeat pregnancy within 18 months of delivery, in a large health system and to determine the impact of contraceptive method on RRP.

STUDY DESIGN

Retrospective cohort.

RESULTS

The prevalence of RRP among patients who delivered in August 2014 (n=804) was 27.2%. After controlling for age and sociodemographic characteristics, women experiencing RRP were less likely to have used long-acting reversible contraception (LARC) [adjusted odds ratio (aOR) 0.45, 95% confidence interval (CI) 0.24-0.85, p=.014; RRP in 19% of implant and 18% of IUD users)] and more likely to have been prescribed a progestin-only pill (aOR 5.106, 95% CI 2.157-12.083, p<.001; RRP in 53% of users) compared to women choosing all other reversible contraceptive methods.

CONCLUSIONS

Postpartum LARC decreases the odds of RRP, while a prescription for progestin-only pills is not protective.

Obstetric Outcomes After Failed Hysteroscopic and Laparoscopic Sterilization Procedures

OBJECTIVE

To compare obstetric outcomes after failed hysteroscopic and laparoscopic sterilization.

METHODS

This retrospective cohort study examined pregnancy outcomes including live birth, preterm birth, stillbirth, spontaneous abortion, therapeutic abortion, ectopic pregnancies, and gestational trophoblastic disease using a commercial claims administrative database for the years 2007-2013. We used a Z-test to compare pregnancy outcomes per 100 person-years based on type of sterilization. Cox proportional hazard models controlled for patient age, geographic region, urbanicity, comorbidities, and insurance type.

RESULTS

We evaluated 997 pregnancy outcomes among 817 women from a total of 70,115 women with a history of either hysteroscopic sterilization (n=387 pregnancies/27,724 cases) or laparoscopic sterilization (n=610 pregnancies/42,391 cases). Women undergoing hysteroscopic sterilization were slightly older than, but otherwise similar to, women undergoing laparoscopic sterilization. The most common outcome was live birth, which was more likely after hysteroscopic sterilization compared with laparoscopic sterilization (adjusted hazard ratio 1.32, 95% CI 1.09-1.60). The rate of spontaneous abortion was not statistically significantly different between the two groups. Therapeutic abortion occurred more often after hysteroscopic sterilization (adjusted hazard ratio 1.49, 95% CI 1.10-2.01), whereas ectopic pregnancies occurred less often (adjusted hazard ratio 0.12, 95% CI 0.05-0.29) compared with laparoscopic sterilization.

CONCLUSION

Hysteroscopic sterilization is associated with higher rates of live birth and lower rates of ectopic pregnancy compared with laparoscopic sterilization. Spontaneous abortion and preterm birth rates were similar in both groups. These data do not support an adverse effect of hysteroscopic sterilization on subsequent pregnancy outcomes.

Women's preferences for permanent contraception method and willingness to be randomized for a hypothetical trial

OBJECTIVE

To understand women's preferences for permanent contraception by salpingectomy or tubal occlusion following standardized counseling and evaluate the practicality of a future randomized trial.

STUDY DESIGN

We invited pregnant and non-pregnant women planning permanent contraception at the University of California, Davis (UCD) and University of Tennessee (UT) Obstetrics and Gynecology clinics to participate. We enrolled women when they received routine counseling and signed procedure consent. Participants received standardized information sheets reviewing permanent contraception options based on pregnancy status then completed an anonymous survey with questions about demographics, method preference, and willingness to participate in a hypothetical randomized trial comparing salpingectomy and tubal occlusion. We evaluated predictors for salpingectomy preference using multivariable analysis.

RESULTS

From July 2015 to October 2016, we enrolled 75 women at UCD and 63 women at UT. Overall, respondents preferred salpingectomy (63.0%); among the 47 women not currently pregnant at both sites, 40 (85.1%) preferred salpingectomy, most commonly because of higher efficacy. Although population characteristics differed significantly between the sites, only UCD site (aOR 4.2; 95% CI 1.9, 9.4) and non-pregnancy status (aOR 4.2; 95% CI 1.6, 10.8) predicted preference for salpingectomy in the multivariable model. Most participants (n=84, 60.9%) would not be willing to be randomized to a theoretical trial comparing salpingectomy and tubal occlusion procedures.

CONCLUSION

Among a diverse group of women from two different areas in the U.S. given a choice of permanent contraception methods, salpingectomy is preferred over tubal occlusion. Most women planning a permanent contraceptive procedure would not agree to a randomized comparison of these methods.

IMPLICATIONS STATEMENT

Salpingectomy, which offers theoretically higher efficacy and potentially greater ovarian cancer protection compared to tubal occlusion, is preferred by the majority of patients and should be offered to all women seeking permanent contraception. Differences in method choices less likely reflect the patient population and more likely the counseling provided.

Family Planning and Pregnancy Management in Adults with Congenital Heart Disease

With advances in congenital heart disease management, there are an increasing number of women reaching reproductive age. Pregnancy results in a surge of hormones and increased demands on both the cardiovascular (CV) and respiratory systems. Depending on the heart defect and the treatments the mother has undergone, these hemodynamic changes can result in an increased risk of maternal CV events and an increased risk of fetal morbidity and mortality. Thus, it is important to have a comprehensive approach to adult congenital heart disease patients involving pre-pregnancy planning in addition to diligent peri- and post-partum care.