Update on permanent contraception options for women

Comparison In Vitro Fertilization Outcomes between DouStim and Minimal Stimulation Protocols in Poor Ovarian Responders: A Randomized Clinical Trial

BACKGROUND

Various protocols have been approved to improve the response rate leading to successful fertilization in poor ovarian responders (PORs). The application of double ovarian stimulation (DuoStim) in the follicular and luteal phases of the same ovarian cycle has been shown as an intriguing option to achieve more oocyte retrievals in the shortest time. The aim of the current study is to compare the outcomes of different protocols, minimal stimulation (MS) and Duostim.

MATERIALS AND METHODS

This randomized clinical trial was performed on 42 in vitro fertilization (IVF) candidates with POR diagnosis. Patients were classified into two equal groups and treated with the DuoStim protocol and MS protocol. The IVF outcomes, including retrieved follicles, oocytes, metaphase II (MII) oocytes and embryos, were compared between these groups.

RESULTS

The patients' characteristics including age, anti-mullerian hormone (AMH), follicle stimulating hormone (FSH), luteinizing hormone (LH), and antral follicle count (AFC) were collected and compared. It showed there was no significant difference between the two groups baseline characteristics (P>0.05). We observed that the DuoStim protocol resulted in a significantly higher score in comparison with the MS protocols , including the number of follicles (6.23 ± 2.93 vs. 1.77 ± 1.66, P<0.001), retrieved oocytes (3.86 ± 2.57 vs. 1.68 ± 1.58, P=0.002), MII oocytes (3.36 ± 2.42 vs. 1.27 ± 1.27, P=0.001) and obtained embryos (2.04 ± 1.64 vs. 0.77 ± 0.86, P=0.003).

CONCLUSION

The DuoStim protocol is a favourable and time saving plan that is associated with more oocytes in a single stimulation cycle. The DuoStim protocol significantly can result in more frequent MII oocytes and embryos. We figured that the higher number of oocytes and embryos might have led to a higher rate of pregnancy (registration number: IRCT20200804048303N1).

Safety reporting of Essure medical device: a qualitative and quantitative assessment on the FDA manufacturer and user facility device experience database in 2018

Background

There have been numerous cases of adverse events since the introduction of Essure medical devices for sterilization in 2002. This study analyzed the safety event reports of the Essure reported in the Manufacturer and User Facility Device Experience (MAUDE).

Methods

A retrospective analysis examined the MAUDE reports between Jan-1, 2018, and Oct-31, 2018 and focused on safety reports related to the Essure device. Safety reports were categorized and analyzed by their event type, device problem, patients' symptoms and the level of harm. Of this study cohort, 10% of samples were randomly selected for quantitative analyses. Thematic analysis was conducted for reports included death cases.

Results

A total of 4,994 eligible reports were analyzed. There were ten reports associated with individuals' deaths, and the main themes of safety reports from qualitative analysis were pains, bleeding, surgery, migraine, and infection. Quantitative analysis of 500 randomly selected samples showed that 98% of adverse event reports were associated with different injuries such as surgery, pain, bleeding, hysterectomy, and menorrhagia. Additionally, more than 90% of reports were submitted by the manufacturer.

Conclusion

These findings indicated several safety issues of Essure. More meaningful pre- and post-marketing surveillance and regulation are warranted in the medical device market to ensure safety and effectiveness, including investigating complaints, promptly sharing relevant information with regulators and users, and implementing corrective actions.

Imaginaries of a laparoscope: power, convenience, and sterilization in rural India

Laparoscopic tubal ligation is the most prevalent method of contraception amongst India's rural and urban poor. Drawing on 18 months of ethnographic fieldwork in rural Rajasthan in 2012-2013, this paper investigates how rural women's perceptions of a biomedical instrument-the laparoscope-influence their perceptions of sterilization, a procedure often entrenched in coercive, target- and incentive-driven population control programme. By investigating how a laparoscope is entangled in global exchanges, national policies, institutional arrangements, and local moral worlds, this paper demonstrates that while wider biomedical discourses perpetuate the narrative of safety and convenience, people's everyday lives inform their understandings of technology that is widely known but rarely seen.

Assessing the Barriers to Postpartum Tubal Ligation Among Multiparous Women

Background: Unmet demands for postpartum tubal ligation are estimated to be greater than the actual number of tubal ligations done, especially in low-resource settings. Through this study, we therefore assessed the barriers to postpartum tubal ligation in the developing world.

Materials and Methods: It is a prospective cohort study including 3671 multiparous women from northern India. Recruited patients were given survey questionnaires during their antenatal and postpartum period which evaluated the patient-related, healthcare facility-related and social factors which were the determining factors for the unfulfillment of their desire for permanent sterilization.

Results: Out of the recruited population, 1576 women wished to undergo tubal ligation. Following attrition, a total of 1024 were followed up prospectively. Of them, sterilization was successfully done only in 309 (30.18%) participants. A large proportion of mothers had their demand unmet (715 mothers; 69.82%). Out of them, 505 (70.63%) women stated that tubal ligation was not done because they did not deliver by Caesarean section. Insufficient counselling regarding tubal ligation was quoted by 325 (45.45%) mothers. Majority of the participants denied tubal ligation as they were not given enough information about the procedure (589 participants; 82.38%). While 568 (79.44%) mothers had changed their mind after delivery, 257 (35.94%) thought that their health was not fit to undergo the procedure and 213 (29.79%) mothers wanted more children in the future. We found that there was strong opposition from their male partners (56.78%).

Conclusion: Postpartum tubal ligation is of paramount importance in women with completed families, especially in developing countries. This prospective study addressed the barriers to tubal ligation, which would help combat future unintended pregnancies.

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.

Comparing options for females seeking permanent contraception in high resource countries: a systematic review

BACKGROUND

Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception.

METHODS

We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis.

RESULTS

Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC.

CONCLUSIONS

Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42016038254].

What are the mechanisms of action of the different contraceptive methods to reduce the risk of ovarian cancer?

OBJECTIVE

Ovarian cancer (OvCa) is the deadliest gynaecologic malignancy. Knowing that OvCa, as a disease, has different origins has allowed us to relate them to the mechanisms of action of different contraceptive methods with the aim of evaluating the possibility of their use in reducing risk.

STUDY DESIGN

This commentary review article will instead focus on the recent findings on the role of contraceptive methods in preventing of OvCa.

RESULTS

Combined hormonal contraceptive (CHC) use is an effective method of chemoprevention for OvCa in the general population and in women with genetic disorders. Salpingectomy, better than tubal ligation, should be offered for ovarian/tubal/peritoneal cancer prevention. Progestogen-only methods can decrease the risk of OvCa via reduced menstrual bleeding and by changes in the hormonal environment that surrounds the ovary. IUDs of any type, through different mechanisms, decrease the risk of OvCa. Barrier methods prevent the passage of germs into the tubes and ovaries and the inflammatory state they produce.

CONCLUSIONS

Most contraceptive methods have a mechanism of action that may favour a reduction in the risk of OvCa. The theories of incessant ovulation, retrograde menstruation, and that the fallopian tubes are the site of origin of a proportion of high-grade serous OvCa, have led to the recommendation that anovulatory methods, those that decrease menstrual bleeding, and those that blocked tubes, or even better, 'opportunistic salpingectomy' are a current approach to prevent OvCa in the population general and, above all, in the population at risk.

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.

Effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for modified Pomeroy salpingectomy: A randomized controlled trial

OBJECTIVE

To examine the effect of simethicone on reducing operative difficulty associated with bowel interference during minilaparotomy for postpartum modified Pomeroy partial salpingectomy.

STUDY DESIGN

We enrolled 20-45-year-old women planning the procedure from March 2018 to February 2019. We randomized participants to chew simethicone 160 mg with water 50 mL 2-8 h before surgery or no treatment. The participants were not blinded; however, surgeons, care providers, and outcome assessors were blinded to the study allocation. We measured surgeon-rated operative difficulty using a 10-cm visual analog scale that represented the difficulty perceived to be resulting from bowel interference. Secondary outcomes included operative time and intraoperative and postoperative complications.

RESULTS

We enrolled 60 women in each group; baseline characteristics and procedural profiles were comparable. Women in the intervention group used simethicone a median of 157 min (interquartile range 127-192) before the procedure. Surgeons rated the procedure difficulty score as 4.8 in the simethicone group and 4.5 in the control group (p = 0.57). Operative time in the two groups were 26 and 24 min, respectively (p = 0.14). We found no difference in intraoperative adverse events including blood loss and mesosalpinx tear, postoperative morbidities, hospital stay, and patient-rated satisfaction scores.

CONCLUSION

Preprocedural simethicone has no demonstrable benefit in reducing operative difficulty caused by bowel interference during minilaparotomy for postpartum tubal sterilization.

IMPLICATIONS

Preprocedural simethicone as given in this study did not result in reduced bowel interference and improved procedure difficulty. Further research examining simethicone in this setting would not be worthwhile as clinically meaningful benefit is unlikely.

Comparing options for women seeking permanent contraception in high-resource countries: a protocol for a systematic review

BACKGROUND

For women seeking permanent contraception, there are a variety of options available including surgical techniques such as tubal ligation or bilateral salpingectomy, in-clinic procedures such as hysteroscopic techniques using micro-inserts, or the levonorgestrel-releasing intrauterine contraceptive. Despite the various methods available for women who are seeking permanent contraception, there is not a review or decision-making tool that systematically brings together outcomes related to effectiveness, tolerability, adverse effects, non-contraceptive benefits, recovery, or accessibility: all of which are important for shared decision-making between patients and health care providers.

METHODS

We registered our protocol [on Prospero: CRD42016038254] following PRISMA guidelines. A search strategy was created in collaboration with a librarian, and three databases (EMBASE, PubMed, Web of Science) will be searched along with secondary screening of relevant articles. A third reviewer will adjudicate any discrepancies. Data will be extracted independently according to population, intervention, comparison, outcomes (PICOS); length of follow-up; and funding. Articles will be assessed for bias using the Newcastle-Ottawa Scale and the Cochrane Collaboration tool. If appropriate, a network meta-analysis will be conducted to rank and analyze each method according to each objective. If heterogeneity between studies is too high or it is not possible to conduct a network meta-analysis, a narrative analysis of the study results will be provided.

DISCUSSION

Clinicians and their patients seeking permanent contraception have several options, yet we were unable to find a systematic review or decision support tool helping to facilitate shared decision-making. This systematic review can inform patients, providers, and health policy decision-makers about which options of permanent contraception will meet different reproductive goals according to various outcomes, which can lead to better health, social, economic, and mental well-being for reproductive age women. This can also aid our understanding of resulting costs to the health care system.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016038254.

Surgical prevention strategies in ovarian cancer

Given the current lack of effective screening for ovarian cancer, surgical removal of at-risk tissue is the most successful strategy to decrease risk of cancer development. However, the optimal timing of surgery and tissues to remove, as well as the appropriate patients to undergo preventive procedures are poorly understood. In this review, we first discuss the origin and precursors of ovarian epithelial carcinomas, focusing on high-grade serous carcinomas and endometriosis-associated carcinomas, which cause the majority of the mortality and incidence of ovarian cancer. In addition, we summarize the implications of current understanding of specific pathogenic origins for surgical prevention and remaining gaps in knowledge. Secondly, we review evidence from the epidemiologic literature on the associations of various surgical prevention strategies, including endometriosis excision, tubal procedures, and bilateral salpingo-oophorectomy, with risk of future ovarian cancer development, as well as the short- and long-term consequences of these strategies on women's health and quality and life. We conclude with recommendations for surgical prevention in women with high-risk genetic mutations and average-risk women, and a brief discussion of ongoing research that will help clarify optimal surgical approaches that balance risk-reduction with maintenance of women's quality of life.

Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it

BACKGROUND

Despite the increased prevalence of reversible contraception, global unintended pregnancy rates are stable. Mistakes, method failures, side effects, alcohol, stock-outs, fears, costs, delays, myths, religious interference, doctors with other priorities, traditions and lack of health professionals may all factor in. Yet these unintended pregnancies - nearly a hundred million annually - cause much individual suffering, and in the long run, can aggravate conflicts, poverty, forced emigration and climate change. Presently, non-poor women postpone childbearing because of longer educational trajectories and careers. Sterilisations are therefore less often regretted or coerced. For poor-resourced women with a completed family, an unwanted pregnancy often has serious consequences, including crossing the (extreme) poverty line in the wrong direction, choosing an unsafe abortion, or even death. Caesarean sections (CSs), which currently stand at around 23 million annually, are increasing. On an "intention-never-to-become-pregnant-again" analysis, choosing a partial, and even more so a total bilateral tubectomy to be implemented during an - anyway performed - CS is by far the most reliable and safe contraceptive choice compared to meaning to start female or male sterilisation or any other contraceptive method later, and it reduces the chance of a future ovarian carcinoma substantially. CSs make subsequent pregnancies more dangerous. Simultaneously, they provide convenient, potentially cost-free opportunities for voluntary permanent contraception (PC): particularly important if there is no guaranteed future access to reliable contraception, safe abortion and well-supervised labour.

PARTIAL SOLUTION

Millions of women are within reach of attaining freedom from the "tyranny of excessive fertility" when they have a CS. Therefore, any woman who might conceivably be of the firm opinion that her family will be (over) completed after delivery should antenatally have "what if you have a CS" counselling to assess whether she would like a tubectomy/ligation. Yet many are not provided with this option: leading to frequent regret, more often than having been giving that choice would.

CONCLUSION

Withholding antenatal counselling about the option of PC for in case the delivery might become a CS is very prevalent, yet often more medically risky, and morally questionable than when, even in labour, a doctor sometimes decides in the absence of earlier counselling, considering numerous factors, to provide the choice to undergo a concurrent sterilisation if s/he is convinced that would be in the patient's best interest.