Ovarian reserve after salpingectomy: a systematic review and meta-analysis

FIGO position statement on opportunistic salpingectomy as an ovarian cancer prevention strategy

Epithelial ovarian cancer, with the highest mortality rate among gynecologic malignancies, often goes undetected until advanced stages due to non-specific symptoms. Traditional prevention strategies such as bilateral salpingo-oophorectomy (BSO) are limited to high-risk women and induce surgical menopause, often leading to significant health concerns. Recent findings suggest that many serous epithelial ovarian cancers originate in the fallopian tubes rather than the ovaries. This has led to the hypothesis that salpingectomy, with preservation of the ovaries, may reduce the risk of ovarian cancer while avoiding the adverse effects of early menopause. Studies show that bilateral salpingectomy (BS) significantly reduces ovarian cancer incidence even in average-risk women. Bilateral salpingectomy has been demonstrated to be safe with minimal added operative time, no adverse effects on ovarian function and is also cost effective. Opportunistic salpingectomy (OS), at the time of non-gynecologic surgeries, is a promising strategy for reducing ovarian cancer risk, especially among average-risk women who have completed childbearing. It offers a safe and cost-effective alternative to traditional methods. Emerging data supports incorporating OS into standard surgical practices for benign gynecologic conditions and considering it during unrelated abdominal/pelvic surgeries after adequate patient counseling and informed consent. Further training of non-gynecologic surgeons in OS is recommended to expand its preventive benefits.

The use of dienogest in treatment of symptomatic adenomyosis: A systematic review and meta-analysis

Adenomyosis is a gynaecological problem that impacts women's quality of life by causing dysmenorrhea, chronic pelvic pain, and menorrhagia. The search continues for the best medical treatment for symptomatic adenomyosis. This systematic review and meta-analysis investigated the role of dienogest, an oral progestin, in reducing pain and bleeding associated with adenomyosis. Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, MEDLINE, Scopus, and Web of Science were searched in January 2024. The primary outcome was pain scores for dysmenorrhea, whereas secondary outcomes were chronic pelvic pain (CPP), uterine volume (UV), and menorrhagia. One comparison was performed comparing outcomes in symptomatic adenomyosis before and after treatment with dienogest. Pooled analysis of included studies reported a statistically significant reduction of dysmenorrhea pain score after dienogest treatment (mean difference -5.86 cm on a 10-cm visual analogue scale, 95 % CI -7.20 to -4.53, I2 = 97 %). Regarding chronic pelvic pain, a meta-analysis of included studies showed a significant decline in pain after treatment (standardized mean difference -2.37, 95 % CI -2.89 to -1.86, I2 = 60 %). However, uterine volume did not differ significantly after treatment (mean difference -4.65 cm3, 95 % CI -43.22 to 33.91). Menorrhagia was improved significantly after treatment (Peto odds ratio 0.07, 95 % CI 0.03 to 0.18). In conclusion, dienogest seems to be effective in controlling painful symptoms and uterine bleeding in women with adenomyosis at short and long-term therapy.

The Impact of Opportunistic Salpingectomy on Ovarian Reserve: A Systematic Review

Background: In the last decade, increasing evidence has suggested that high-grade serous ovarian cancers may have their origin in the fallopian tube rather than the ovary. This emerging theory presents an opportunity to prevent epithelial ovarian cancer by incorporating prophylactic bilateral salpingectomy into all surgical procedures for average-risk women. The aim of this review is to investigate the hypothesis that bilateral salpingectomy (BS) may have a negative impact on ovarian reserve, not only following hysterectomy for benign uterine pathologies but also when performed during cesarean sections as a method of sterilization or as a treatment for hydrosalpinx in Assisted Reproductive Technology interventions. Methods: PubMed, Medline, Google Scholar, and Cochrane were searched for original studies, meta-analyses, and opinion articles published between 2014 and 2024. Results: Out of 114 records from the database search, after the removal of duplicates, 102 articles were considered relevant for the current study. Conclusions: Performing opportunistic salpingectomy seems to have no adverse impact on ovarian function in the short term. However, because there is an existing risk of damaging ovarian blood supply during salpingectomy, there are concerns about potential long-term adverse effects on the ovarian reserve, which need further investigation.

The Effect of Salpingectomy on Ovarian Reserve Using Two Different Electrosurgical Instruments: Ultrasonic Shears Versus Bipolar Electrocautery

Background Salpingectomy is a common surgical procedure in gynecology performed for various indications. Given its proximity to the ovaries and shared vascular supply, concerns have arisen regarding compromised ovarian reserve post-salpingectomy. Objective We aim to study the effect of two different energy sources (group 1: salpingectomy using bipolar electrocautery followed by division with scissors versus group 2: salpingectomy with ultrasonic shears) on residual ovarian reserve. The effect on ovarian reserve was assessed using serum levels of follicle-stimulating hormone (FSH), anti-Müllerian hormone (AMH), antral follicle count (AFC), and ovarian size pre- and postoperatively. Materials and methods According to the inclusion criteria, 68 women were included in the study and randomized into the bipolar electrocautery group and the ultrasonic shear group. The final analysis included 34 women in the bipolar electrocautery group and 32 in the ultrasonic shear group. Preoperatively, the ovarian reserve of all women was assessed using FSH, AMH, AFC, and ovarian size. These parameters were then reassessed at three months postoperatively, and the percentage change was analyzed. Results The mean baseline serum AMH and serum FSH values in the bipolar electrocautery group were 3.9 ± 2.9 ng/ml and 6.6 ± 2.1 IU/L, respectively, comparable with the values in the ultrasonic shear group, where serum AMH was 3.2 ± 2.9 ng/ml and serum FSH was 7.3 ± 3.9 IU/L. AFC and ovarian size were comparable between the two groups preoperatively (bipolar electrocautery group AFC was 8 ± 2.2, ovarian size on the right side was 3.3 ± 0.7 cm and on the left was 3.2 ± 0.6 cm; ultrasonic shear group AFC was 5.7 ± 2.3, ovarian size on the right side was 3.4 ± 0.8 cm and on the left was 3.2 ± 0.8 cm). After three months of postoperative analysis, AFC showed a significant fall from the preoperative value in the bipolar electrocautery group compared to the ultrasonic shear group (AFC reduced from 8 ± 2.2 to 5.5 ± 2.3 vs. 8.6 ± 0.5 to 7.9 ± 2.3; p=0.002). The other parameters showed no statistically significant change. Conclusion Our study suggests that ultrasonic shear is safer than bipolar electrocautery for preserving ovarian reserve after salpingectomy. However, further research is needed to confirm these findings.

Feasibility, Safety, and Provider Perspectives of Bipolar Electrosurgical Cautery Device for (Opportunistic or Complete) Salpingectomy at the Time of Cesarean Delivery

OBJECTIVE

The aim of the study is to evaluate the use of a bipolar electrocautery device for complete salpingectomy at cesarean to improve procedure completion rates, operative time, and surgeon reported satisfaction as compared with standard bilateral tubal ligation (BTL) and suture-cut-tie salpingectomy.

STUDY DESIGN

This is a prospective cohort study of women undergoing planned, non-emergent cesarean with desired sterilization with complete salpingectomy utilizing a bipolar electrocautery device. Study patients were compared with historic controls from a randomized controlled trial (RCT) of complete salpingectomy via suture-cut-tie method versus BTL conducted at our institution (SCORE trial, NCT02374827). Outcomes were compared with groups from the original RCT.

RESULTS

Thirty-nine women were consecutively enrolled (12/2018-11/2019) into the device arm of the study and compared with the original SCORE cohort (n = 40 BTL, n = 40 salpingectomy without a device). Salpingectomy performance with the bipolar electrocautery device was successfully completed in 100% (39/39) of enrolled women, with one device failure requiring the use of a second device, as compared with 95% (38/40) in the BTL (p = 0.49) and 67.5% (27/40) in salpingectomies without a device (p < 0.001). Mean operative time of sterilization procedure alone demonstrated device use as having the shortest operative time of all (device salpingectomy 5.0 ± 3.6 vs. no device 18.5 ± 8.3 minutes, p < 0.001; and vs. BTL 6.9 ± 5.0, p = 0.032). Mean sterilization procedure endoscopic band ligation (EBL) was demonstrated to be significantly different between each group, least amongst BTL followed by device (6.3 ± 4.8 vs. 8.4 ± 24.8, p < 0.001), and most by suture-cut-tie method (17.7 ± 14.3, p < 0.001 compared with device). Surgeon reported attitudes of complete salpingectomy performance in general practice outside an academic setting was greater with a device than without (79.5 vs. 35.3%; p < 0.001).

CONCLUSION

Use of a bipolar electrocautery device improved operative times and surgeon satisfaction for salpingectomy at cesarean over standard suture ligation. Device use improved surgeon reported outcomes and may improve incorporation of complete salpingectomy at cesarean.

KEY POINTS

· Electrocautery bipolar device use was safe at the time of salpingectomy during cesarean.. · Greater surgeon satisfaction occurs using a device than without.. · Decreased surgical time with device use is seen making the procedure equal to BTL..

Comparison of salpingectomy and tubal occlusion for hydrosalpinx in in-vitro fertilization outcome

The occurrence of hydrosalpinx can reduce the success rate of assisted reproductive technology. The laparoscopic salpingectomy and tubal occlusion have been shown to improve in-vitro fertilization (IVF) outcomes in this disease. The primary goal of this review was to assess and compare the IVF outcome following salpingectomy or tubal occlusion in the published literature. The authors included studies with at least one of the following outcomes: days of controlled ovarian hyperstimulation, retrieved oocyte number, fertilization rates, clinical pregnancy rate, miscarriage rate, or ectopic pregnancy rate. In conclusion, proximal tubal occlusion outperforms salpingectomy in terms of fertilization rate while offering no evident advantages in terms of days of controlled ovarian hyperstimulation, retrieved oocytes number, IVF results, or problems in treating hydrosalpinx patients prior to IVF. These data may help clinicians choose the best therapy for patients with hydrosalpinx prior to IVF.

Beyond Sterilization: A Comprehensive Review on the Safety and Efficacy of Opportunistic Salpingectomy as a Preventative Strategy for Ovarian Cancer

Ovarian cancer (OC) is Canada's third most common gynecological cancer, with an estimated 3000 new cases and 1950 deaths projected in 2022. No effective screening has been found to identify OC, especially the most common subtype, high-grade serous carcinoma (HGSC), at an earlier, curable stage. In patients with hereditary predispositions such as BRCA mutations, the rates of HGSC are significantly elevated, leading to the use of risk-reducing salpingo-oophorectomy as the key preventative intervention. Although surgery has been shown to prevent HGSC in high-risk women, the associated premature menopause has adverse long-term sequelae and mortality due to non-cancer causes. The fact that 75% of HGSCs are sporadic means that most women diagnosed with HGSC will not have had the option to avail of either screening or prevention. Recent research suggests that the fimbrial distal fallopian tube is the most likely origin of HGSC. This has led to the development of a prevention plan for the general population: opportunistic salpingectomy, the removal of both fallopian tubes. This article aims to compile and review the studies evaluating the effect of opportunistic salpingectomy on surgical-related complications, ovarian reserve, cost, and OC incidence when performed along with hysterectomy or instead of tubal ligation in the general population.

A Study to Evaluate the Effect of Opportunistic Salpingectomy on Ovarian Reserve and Function

Background

There are conflicting reports on status of ovarian function after hysterectomy and opportunistic salpingectomy in premenopausal women. The present study was undertaken to understand the effect of salpingectomy done at the time of hysterectomy on ovarian reserve and function as measured by serum AMH and FSH levels before and after the surgery.

Methods

This was a prospective study conducted on 60 women who underwent hysterectomy at our tertiary care centre, Shri Guru Ram Rai Institute of medical and health sciences, Dehradun, from January 2020 to September 2021. Serum AMH and FSH levels were monitored preoperatively and 3 months postoperatively in patients undergoing hysterectomy with bilateral salpingectomy and hysterectomy without salpingectomy.

Results

The mean age of the patients was 41.83 yrs in group 1 and 43.73 yrs in group 2 [p value = 0.078]. Most common indication of hysterectomy was AUB-L in both the groups (86% and 80%, respectively). Mean operative time was 115.50 min in group 1 and 114.40 min in group 2 [p value = 0.823]. Mean intra-operative blood loss was 214 ml in group 1 and 199.33 ml in group 2 [p value = 0.087]. Serum AMH and FSH were insignificantly decreased in both the groups post-operatively after 3 months, and the difference between both groups was also not statistically significant.

Conclusion

Salpingectomy done at the time of hysterectomy for benign indications with preservation of ovaries did not have any short-term adverse effects on ovarian reserve and function.

Possible Association of Hysterectomy Accompanied with Opportunistic Salpingectomy with Early Menopause: A Retrospective Cohort Study

Opportunistic salpingectomies (OSs) are concurrently performed with hysterectomies to prevent epithelial ovarian cancer. This study aimed to investigate the correlation between OS and early menopause in females who have undergone hysterectomies. This was a retrospective cohort study involving 79 females who had undergone a hysterectomy, with or without an OS, between January 2007 and December 2015. Their ages at surgery, at menopause, and the lengths of time from surgery to menopause were compared. An OS had been performed in 54 and not performed in 25 of the enrolled patients, comprising the OS and non-OS groups. Body mass index was significantly higher in the OS group (OS: 25.27 ± 4.17 vs. non-OS: 22.97 ± 3.27, p = 0.01). Additionally, menopausal sleep problems were more prevalent in the OS group than in the non-OS group (41% vs. 12%, p = 0.01). Notably, the time from surgery to menopause was significantly shorter in the OS group than in the non-OS group (OS: 1.84 ± 1.85 vs. non-OS: 2.93 ± 2.43, p = 0.031). After adjusting the covariates, the OS group was associated with a significantly shorter period between surgery and menopause (p = 0.029). In conclusion, these results showed that a hysterectomy plus an OS might cause earlier menopause than a hysterectomy only. An OS should be preoperatively discussed with patients regarding the possibility of early menopause. The findings of this study require further large-scale investigations to reinforce the results.

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.

Effect of salpingectomy on ovarian reserve: A systematic review and meta-analysis

AIM

To determine the effect of salpingectomy on ovarian reserve.

METHODS

PubMed, EMBASE, Web of Science, Dynamed plus, and Cochrane Controlled Trials Register databases were searched from their inception to December 2020 to identify relevant studies, including cross-sectional studies, retrospective studies, and randomized controlled trials. Studies that compared anti-Müllerian hormone (AMH) levels and/or antral follicle count (AFC) between the control and salpingectomy groups or before and after surgery were included.

RESULTS

Twenty-one articles were included in the systematic review. Meta-analyses were performed on 16 studies in which data were presented as mean ± SD values. A meta-analysis comparing AMH levels before and after surgery in the same patients showed no significant decrease in all cases, irrespective of whether it was unilateral or bilateral salpingectomy. There was no significant decrease in the AFC in the meta-analysis comparing levels before and after bilateral salpingectomy, either. In contrast, in the case-controlled study the salpingectomy group had significantly lower levels of AMH in all meta-analyses of unilateral and bilateral surgery (mean difference: -0.31, 95% confidence interval [CI]: -0.55, -0.07), only unilateral cases (mean difference: -0.28, 95% CI: -0.50, -0.06), and only bilateral cases (mean difference: -0.71, 95% CI: -1.19, -0.23). The salpingectomy group that included unilateral and bilateral cases had significantly lower AFC compared with no-surgery controls (mean difference: -1.31, 95% CI: -2.13, -0.48).

CONCLUSION

Although not conclusive, it does appear that patients who underwent salpingectomy (either unilateral or bilateral) have a decreased ovarian reserve.

Prior salpingectomy impairs the retrieved oocyte number in in vitro fertilization cycles of women under 35 years old without optimal ovarian reserve

STUDY OBJECTIVE

The impairment of the ovarian response in in vitro fertilization (IVF) cycles after salpingectomy remains contentious. Therefore, we investigated whether a history of salpingectomy affects the number of oocytes retrieved in women undergoing IVF in comparison with the number in women without underlying tubal disease.

DESIGN

Case-control study (Canadian Task Force Classification II-2).

SETTING

A tertiary hospital-affiliated fertility center.

PATIENTS

Fifty-four women aged <35 years with a history of salpingectomy and 59 age-matched women without tubal disease.

INTERVENTIONS

Gonadotropin-releasing hormone antagonist protocol for controlled ovarian stimulation and transvaginal oocyte retrieval.

MEASUREMENTS AND MAIN RESULTS

The antral follicle count (AFC), anti-Müllerian hormone (AMH) levels, and the number of retrieved oocytes were significantly lower in women with prior salpingectomy than in women without tubal disease. Day-3 follicle-stimulating hormone (FSH) levels, total gonadotropin dosage, and stimulation days did not significantly differ between the groups. The indications of salpingectomy (i.e., hydrosalpinx and ectopic pregnancy) did not differ significantly in terms of ovarian response or reserve among women with salpingectomy history. A history of salpingectomy and other factors related to ovarian response in IVF, such as age, AMH, AFC, day-3 FSH, and total gonadotropin dose, were significantly correlated with the number of oocytes retrieved by univariate regression analysis. In the multivariate-adjusted model after controlling all the above-mentioned variables, only AFC and AMH levels continued to exhibit significant associations with the number of retrieved oocytes. In a subgroup analysis, the negative impact of prior salpingectomy on the number of retrieved oocytes was especially significant in women with suboptimal ovarian reserves (defined as AMH < 4 ng/mL), regardless of the indication of salpingectomy or whether salpingectomy was bilateral or unilateral.

CONCLUSION

A negative effect on the number of retrieved oocytes in the subsequent IVF cycle after salpingectomy is more likely in women aged <35 years with suboptimal ovarian reserve. Nevertheless, postsurgical AMH and AFC levels still possess a more direct predictive value on ovarian response than the history of salpingectomy.

Ovarian Response, Pregnancy Outcomes, and Complications Between Salpingectomy and Proximal Tubal Occlusion in Hydrosalpinx Patients Before in vitro Fertilization: A Meta-Analysis

Objectives

Contradictory findings exist in studies comparing salpingectomy and proximal tubal occlusion (PTO) in treating hydrosalpinx patients before in vitro fertilization (IVF). Therefore, this meta-analysis aimed to comprehensively compare ovarian response, pregnancy outcomes, and complications between salpingectomy and PTO in treating these patients.

Methods

Embase, PubMed, and Web of Science were searched to identify relevant articles published from 1980 to August 31, 2020. Eight studies that involve 716 hydrosalpinx patients before IVF were included, among whom 408 patients received salpingectomy and 308 patients received PTO. The data were pooled; the standardized mean difference (SMD) or odds ratio (OR) was calculated.

Results

Proximal tubal occlusion-treated patients had higher fertilization rate (SMD = 0.35, 95% CI: 0.11–0.59), while similar days of controlled ovarian hyperstimulation (COH) (SMD: 0.15, 95% CI: −0.36–0.67) and number of retrieved oocytes (SMD = −0.22, 95% CI: −0.54–0.10) compared with salpingectomy-treated patients. Furthermore, no difference of implantation rate (OR = 1.17, 95% CI: 0.62–2.20), clinical pregnancy rate (OR = 0.82, 95% CI: 0.59–1.15), ongoing pregnancy rate (OR = 0.64, 95% CI: 0.36–1.13), or live birth rate (OR = 0.67, 95% CI: 0.16–2.72) was shown between salpingectomy-treated patients and PTO-treated patients. Additionally, ectopic pregnancy rate (OR = 1.13, 95% CI: 0.21–5.92) and miscarriage rate (OR = 0.88, 95% CI: 0.31–2.48) were similar between salpingectomy-treated patients and PTO-treated patients.

Conclusion

Proximal tubal occlusion exhibits a higher fertilization rate but no obvious benefits on days of COH, number of retrieved oocytes, pregnancy outcomes, and complications over salpingectomy in hydrosalpinx patients before IVF.

A retrospective cohort study of tubal occlusion or salpingectomy for permanent contraception in Australia

BACKGROUND

Laparoscopic permanent contraception was previously accomplished most commonly using tubal occlusion procedures. Bilateral salpingectomy (BS) has recently been introduced as an alternative due to possibly superior contraception and greater protection against ovarian cancer.

AIMS

The aim of this study is to assess uptake, feasibility and perioperative outcomes of laparoscopic BS as an alternative to tubal occlusion in Australia.

MATERIALS AND METHODS

A retrospective review of permanent female contraception at two Australian hospitals from January 2014 through December 2020 was performed. The primary outcome was the uptake of BS. Secondary outcomes were feasibility, procedure length, number of ports, perioperative complications and admission length.

RESULTS

A total of 414 women were included; 92 (22.2%) underwent BS and 322 (77.8%) underwent tubal occlusion. There was a slow uptake of BS from 2014 to 2016 (0-3.2%), with a steep uptake from 2017 to 2020 (30-72%) (P = 0.001). Procedure feasibility was 96.8% (62/64) and 99.3% (282/284) for BS and tubal occlusion group, respectively (P = 0.64). BS procedure time was longer by 23 min (P < 0.001). Three or more surgical ports were used in all cases of BS compared to 4.5% of the tubal occlusion group (P < 0.001). There were no intraoperative complications. There were nine and six postoperative complications in the tubal occlusion versus BS group, respectively (P = 0.10). The median admission length was 7.1 (tubal occlusion) versus 7.3 (BS) h (P = 0.10), with five unintended overnight admissions.

CONCLUSION

BS is an increasing choice for permanent contraception. It appears equally feasible as tubal occlusion but typically requires a longer procedure time and a minimum of three surgical ports.

Efficacy and safety of sterilisation procedures to reduce the risk of epithelial ovarian cancer: a systematic review comparing salpingectomy with tubal ligation

PURPOSE

The objective of this systematic review is to evaluate current literature comparing salpingectomy for sterilisation with tubal ligation, regarding the effectiveness and safety, and assess the certainty of evidence.

MATERIALS AND METHODS

PubMed, Cochrane, and Embase databases were searched. Randomised (RCT) and observational studies were included. Articles were quality assessed and data extracted by two independent authors. Certainty of evidence was assessed using GRADE.

RESULTS

Of 2020 articles, 17 were included. No study investigated the risk of EOC. No difference in anti-Müllerian hormone was reported in one RCT at caesarean section (CS). Two cohort studies evaluated ovarian function with surrogate measures and found no difference at caesarean section. Complications did not differ but were inconsistently reported. Laparoscopic tubal ligation was 7 min faster (95% CI 3.8-10.5). Operative time at caesarean section was dependent on the use of surgical devices. Certainty of evidence was low or very low for all estimates, indicating knowledge gaps. Reliable safety data on salpingectomy for sterilisation is lacking, and there is no effectiveness data. Presently, women cannot be properly counselled regarding salpingectomy for sterilisation.

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.

Knowledge of iatrogenic premature ovarian insufficiency among Chinese obstetricians and gynaecologists: a national questionnaire survey

Background

With increasing cases of iatrogenic premature ovarian insufficiency (POI), more clinicians are required to counsel patients regarding the gonadotoxic effects of iatrogenic treatments. This survey aimed to explore obstetricians and gynaecologists’ knowledge regarding iatrogenic POI. A national online questionnaire survey was conducted across China. Respondents were asked to select the iatrogenic condition(s) that can cause POI based on their experience and knowledge.

Results

Of the 5523 returned questionnaires, 4995 were analysed. Among tumour therapies causing POI, most respondents agreed that radiotherapy (73.5% of respondents) and chemotherapy (64.1%) are risk factors for POI. While only 6.5 and 7.8% of the gynaecological oncologists believed that tumour immunotherapy and tumour-targeting therapy, respectively, may cause ovarian impairment, 31.8 and 22.2% of the non-gynaecologic oncologists believed that these therapies could affect ovarian health. Most respondents believed that ovarian cystectomy (54.4%) was a risk factor for POI. In contrast, only a few respondents believed that hysterectomy with bilateral salpingectomy (39.6%) and uterine artery embolisation (33.5%) could cause ovarian impairment. Only 30.5% of respondents believed that immunosuppressants (ISs) increased the risk of POI. Views differed with experience and hospital setting.

Conclusions

The knowledge of gonadal toxicity due to traditional tumour treatments is generally high among Chinese obstetricians and gynaecologists. A misunderstanding may exist in primary care hospitals and general gynaecologists regarding a link between novel tumour treatments and POI, owing to the lack of convincing evidence. Knowledge of POI caused by hysterectomy and ISs should be improved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13048-020-00739-z.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

BACKGROUND

Tubal disease accounts for 20% of infertility cases. Hydrosalpinx, caused by distal tubal occlusion leading to fluid accumulation in the tube(s), is a particularly severe form of tubal disease negatively affecting the outcomes of assisted reproductive technology (ART). It is thought that tubal surgery may improve the outcome of ART in women with hydrosalpinges.

OBJECTIVES

To assess the effectiveness and safety of tubal surgery in women with hydrosalpinges prior to undergoing conventional in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI).

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, DARE, and two trial registers on 8 January 2020, together with reference checking and contact with study authors and experts in the field to identify additional trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing surgical treatment versus no surgical treatment, or comparing surgical interventions head-to-head, in women with tubal disease prior to undergoing IVF.

DATA COLLECTION AND ANALYSIS

We used Cochrane's standard methodological procedures. The primary outcomes were live birth rate (LBR) and surgical complication rate per woman randomised. Secondary outcomes included clinical, multiple and ectopic pregnancy rates, miscarriage rates and mean numbers of oocytes retrieved and of embryos obtained.

MAIN RESULTS

We included 11 parallel-design RCTs, involving a total of 1386 participants. The included trials compared different types of tubal surgery (salpingectomy, tubal occlusion or transvaginal aspiration of hydrosalpingeal fluid) to no tubal surgery, or individual interventions to one another. We assessed no studies as being at low risk of bias across all domains, with the main limitations being lack of blinding, wide confidence intervals and low event and sample sizes. We used GRADE methodology to rate the quality of the evidence. Apart from one moderate-quality result in one review comparison, the evidence provided by these 11 trials ranged between very low- to low-quality. Salpingectomy versus no tubal surgery No included study reported on LBR for this comparison. We are uncertain of the effect of salpingectomy on surgical complications such as the rate of conversion to laparotomy (Peto odds ratio (OR) 5.80, 95% confidence interval (CI) 0.11 to 303.69; one RCT; n = 204; very low-quality evidence) and pelvic infection (Peto OR 5.80, 95% CI 0.11 to 303.69; one RCT; n = 204; very low-quality evidence). Salpingectomy probably increases clinical pregnancy rate (CPR) versus no surgery (risk ratio (RR) 2.02, 95% CI 1.44 to 2.82; four RCTs; n = 455; I² = 42.5%; moderate-quality evidence). This suggests that in women with a CPR of approximately 19% without tubal surgery, the rate with salpingectomy lies between 27% and 52%. Proximal tubal occlusion versus no surgery No study reported on LBR and surgical complication rate for this comparison. Tubal occlusion may increase CPR compared to no tubal surgery (RR 3.21, 95% CI 1.72 to 5.99; two RCTs; n = 209; I² = 0%; low-quality evidence). This suggests that with a CPR of approximately 12% without tubal surgery, the rate with tubal occlusion lies between 21% and 74%. Transvaginal aspiration of hydrosalpingeal fluid versus no surgery No study reported on LBR for this comparison, and there was insufficient evidence to identify a difference in surgical complication rate between groups (Peto OR not estimable; one RCT; n = 176). We are uncertain whether transvaginal aspiration of hydrosalpingeal fluid increases CPR compared to no tubal surgery (RR 1.67, 95% CI 1.10 to 2.55; three RCTs; n = 311; I² = 0%; very low-quality evidence). Laparoscopic proximal tubal occlusion versus laparoscopic salpingectomy We are uncertain of the effect of laparoscopic proximal tubal occlusion versus laparoscopic salpingectomy on LBR (RR 1.21, 95% CI 0.76 to 1.95; one RCT; n = 165; very low-quality evidence) and CPR (RR 0.81, 95% CI 0.62 to 1.07; three RCTs; n = 347; I² = 77%; very low-quality evidence). No study reported on surgical complication rate for this comparison. Transvaginal aspiration of hydrosalpingeal fluid versus laparoscopic salpingectomy No study reported on LBR for this comparison, and there was insufficient evidence to identify a difference in surgical complication rate between groups (Peto OR not estimable; one RCT; n = 160). We are uncertain of the effect of transvaginal aspiration of hydrosalpingeal fluid versus laparoscopic salpingectomy on CPR (RR 0.69, 95% CI 0.44 to 1.07; one RCT; n = 160; very low-quality evidence).

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that salpingectomy prior to ART probably increases the CPR compared to no surgery in women with hydrosalpinges. When comparing tubal occlusion to no intervention, we found that tubal occlusion may increase CPR, although the evidence was of low quality. We found insufficient evidence of any effect on procedure- or pregnancy-related adverse events when comparing tubal surgery to no intervention. Importantly, none of the studies reported on long term fertility outcomes. Further high-quality trials are required to definitely determine the impact of tubal surgery on IVF and pregnancy outcomes of women with hydrosalpinges, particularly for LBR and surgical complications; and to investigate the relative efficacy and safety of the different surgical modalities in the treatment of hydrosalpinges prior to ART.

Salpingectomy at the Time of Cesarean Delivery: A Systematic Review and Meta-analysis

OBJECTIVE

To compare the differences in operative time and surgical outcomes between salpingectomy and standard tubal interruption at the time of cesarean delivery.

DATA SOURCES

PubMed, Medline, Google Scholar, Cochrane, and ClinicalTrials.gov were searched from inception until July 2019 for articles reporting outcomes for women undergoing salpingectomy during cesarean delivery compared with women undergoing standard sterilization methods.

METHODS OF STUDY SELECTION

Studies were selected if they included the main outcome of operative time or additional outcomes, which included infection, transfusion, readmission, change in hematocrit, and estimated blood loss. The Newcastle-Ottawa Quality Assessment scale or Cochrane Handbook were used to assess quality of cohort and randomized controlled trials (RCTs), respectively. A random-effects model was employed to calculate pooled relative risk or weighted mean difference for each outcome with their 95% CI. Heterogeneity was assessed using the I statistic, and L'Abbé plots were inspected visually to assess for homogeneity.

TABULATION, INTEGRATION, AND RESULTS

We identified 11 studies comprising 320,443 women undergoing total salpingectomy or standard sterilization methods at the time of cesarean delivery. Three RCTs and eight retrospective cohort studies were investigated separately by meta-analysis. When compared with standard sterilization methods, total operative time for patients receiving salpingectomy was significantly longer (6.3 minutes, 95% CI 3.5-9.1, seven studies, 7,303 patients) for cohort studies. With the three RCTs of 163 patients, total operative time was not significantly increased in women receiving salpingectomy (8.1 minutes, 95% CI -4.4 to 20.7). The salpingectomy group did not have an increased risk of wound infection, transfusion, readmission, reoperation, internal organ damage, blood loss, change in hemoglobin, or length of stay when compared with standard sterilization methods.

CONCLUSION

Salpingectomy at the time of cesarean delivery was associated with a small increase in operative time; however, it was not associated with an increased rate of surgical complications. This option should be considered for patients desiring sterilization during cesarean delivery.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42019145247.

Management of Hydrosalpinx in the Era of Assisted Reproductive Technology: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis evaluating the effect of hydrosalpinx on pregnancy outcomes, to compare different types of management of hydrosalpinx and their impact on pregnancy rates as well as on the ovarian reserve.

DATA SOURCES

Electronic search using Pubmed, EMBASE, Ovid MEDLINE, Google Scholar, ClinicalTrials.gov, and Cochrane Central Register of Controlled Trials and including all published studies that examined tubal infertility and its management (assisted reproductive technology or surgery) as well as the effects on ovarian reserve. The following medical subject headings (Mesh) terms combinations were used: "fallopian tube disease," hydrosalpinx," "tubal or salpinx occlusion or obstruction," "in vitro fertilization," "fallopian tube surgery," "salpingectomy," "salpingostomy," "infertility," "subfertility," "sterility" and "ovarian reserve."

METHODS OF STUDY SELECTION

All randomized trials, cohort, and case controls studies were included. We excluded review articles, meeting abstracts, case series and case reports, and abstracts without access to full texts. The search was limited to trials in humans and published in English.

TABULATION, INTEGRATION, AND RESULTS

Our electronic search initially retrieved 6354 articles. Finally, 19 studies were included in the quantitative evaluation of the effects of hydrosalpinx: 23 in the qualitative evaluation and 5 in the quantitative evaluation of different types of hydrosalpinx treatments; and 17 in the quantitative evaluation of ovarian reserve. The presence of a hydrosalpinx was associated with decreased rates of implantation and clinical pregnancy, and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx with salpingectomy, tubal occlusion, or hydrosalpinx aspiration led to better in vitro fertilization pregnancy rates. We found no difference in ovarian response to stimulation after salpingectomy except a decrease in antimüllerian hormone compared to no surgery.

CONCLUSIONS

The presence of hydrosalpinx is associated with decreased pregnancy rate and increased rates of ectopic pregnancy and miscarriage. Management of hydrosalpinx, regardless of the type of treatment, leads to an increased chance of pregnancy.

Serous carcinoma of a prolapsed fallopian tube: A rare cause of a vaginal apex mass

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Vaginal masses after hysterectomy for benign indications should be investigated.

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Opportunistic salpingectomies may decrease incidence of epithelial ovarian cancers.

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Consider regular pelvic exams for women with asymptomatic prolapsed fallopian tubes.

Background

Case

Conclusion

Salpingectomy may decrease antral follicle count but not live birth rate for IVF-ET patients aged 35-39 years: a retrospective study

Purpose

Problems with fallopian tubes are one of the main reasons for women to undergo in vitro fertilization-embryo transfer (IVF-ET). A large proportion of women with ectopic pregnancy, fallopian tube obstruction and hydrosalpinx have had one or both fallopian tubes removed by salpingectomy. With increasing age, ovarian reserve deteriorates, the numbers of retrieved oocytes, available embryos and high-quality embryos are reduced, and the live birth rate for women treated with IVF treatment is affected. Thus, it is important to understand how salpingectomy affects live birth rates for IVF patients of different ages. This study analyzed how patients’ age and salpingectomy influenced ovarian reserve, ovarian response and pregnancy outcomes for infertile women undergoing IVF-ET.

Methods

A total of 1922 patients that underwent IVF-ET treatment from January 1, 2012, to December 31, 2018, were included in this retrospective study. The patients were divided into two groups according to whether or not they had a previous history of salpingectomy. The salpingectomy (group A, 534 patients) and control groups (group B, 1388 patients) were then further divided into two subgroups according to patient age (age<35 years, and age 35–39 years). Ovarian reserve, ovarian response, and IVF outcomes were investigated for each subgroup. Logistic regression model was used to estimate the relationship between clinical pregnancy and live births and patients’ baseline characteristics.

Results

In the salpingectomy group, antral follicle counts (AFC) were significantly lower for the subgroup aged 35 to 39 years compared with the control group. But this difference did not appear in women younger than 35 years. In addition, there were no significant differences in levels of basal follicle stimulation hormone (FSH), basal luteinizing hormone (LH), basal estradiol (E₂), total gonadotropins (Gn) dose, duration of Gn, numbers of retrieved oocytes, fertilization rates, numbers of available embryos, live birth rates, clinical pregnancy rates, miscarriage rates, ectopic pregnancy rates, or multiple pregnancy rates between the salpingectomy group and the control group (P > 0.05). Age is a risk factor for the clinical pregnancy and live birth.

Conclusion

Salpingectomy may decrease antral follicle count but not live birth rate for IVF-ET patients aged 35–39 years. The increased female age was negative related with clinical pregnancy and live birth.

Comparison of the efficacy between bilateral proximal tubal occlusion and total salpingectomy on ovarian reserve and the cholinergic system: an experimental study

Background and aim

To compare the effects of bilateral proximal tubal occlusion and bilateral total salpingectomy on ovarian reserve and the cholinergic system via rat experiment.

Materials and methods

Twenty-one adult female rats were randomly divided into the following three groups:G1 (n = 7), sham group;G2 (n = 7), bilateral total salpingectomy group; and G3 (n = 7), bilateral proximal tubal occlusion group. Four weeks later, the abdomen of the rats was opened. The right ovarian tissues were stored in 10% formaldehyde, whereas the left ovarian tissues were stored at –80 °C in aluminum foil. Serum samples were evaluated for antimullerian hormone. The right ovary was used for histological and immunoreactive examination, and the left ovary was used for tissue MDA analysis. Tissue samples were analyzed for MDA levels with spectrophotometric measurement, apoptosis with TUNEL staining, fibrosis score with Mason trichrome staining, ovarian reserve with HE staining, and cholinergic receptor muscarinic 1 (CHRM1) level with immunoreactivity method.

Results

Compared to G1 and G3, the number of corpus luteum with secondary follicles was significantly lower in G2, whereas the number of ovarian cysts and fibrosis and apoptosis scores increased significantly. The CHRM1 immunoreactivity was significantly lower in G2 than in G1 and G3.

Conclusions

Compared to the bilateral proximal tubal occlusion performed by using bipolar cautery, bilateral total salpingectomy in rats leads to a significant damage in ovarian histopathology and the cholinergic system.

Rationale for opportunistic salpingectomy during gynecological surgery for a benign condition: A review of the available literature

INTRODUCTION

Recent discoveries have shed light on the benefits of opportunistic salpingectomy in the prevention of ovarian cancer. However, in this time of increasing interest in the parameters of ovarian reserve, there are no national recommendations on the subject. This literature review provides an enlightened look at the rationale for performing an opportunistic salpingectomy.

OBJECTIVES

To evaluate the benefits and risks associated with opportunistic salpingectomy during surgery for a benign gynecological condition.

MATERIAL AND METHODS

We carried out a systematic review of the literature using the Pubmed/Medline search engine and the Cochrane database.

RESULTS

A total of 61 articles were selected from over 300 references. The protective impact against cancer, which is widely demonstrated in the literature, is proof of the benefit of this procedure. Furthermore, no increase in intraoperative morbidity has been noted. However, the clinical impact on the ovarian reserve remains uncertain (in particular the occurrence of early pre-menopausal symptoms during the perimenopausal period). Nonetheless, the socioeconomic analysis supports performing opportunistic salpingectomy.

CONCLUSION

Performing opportunistic salpingectomy does not appear to cause an increase in morbidity but the impact on ovarian function is uncertain. The fact that there is a proven benefit of such a procedure against cancer indicates that prior to any surgery a clear discussion should be held with the patient in which they should be fully informed.

Gynecologic Surgical Outcomes Through the Patient's Eyes: Are Physicians Looking in the Same Direction?

Importance

Patient-centered care integrates the highest clinical standards with patient preferences surrounding their treatment. Increasing focus is being placed on the identification of patient-centered outcomes to optimize the impact of medical treatments on patient quality of life, as defined by patients themselves.

Objective

This article will review the central concepts of patient-centered outcomes in benign gynecologic surgery. This expert review will serve as a practical guide for surgeons to incorporate patient preferences into shared surgical decision making.

Evidence Acquisition

The current literature is examined, defining those outcomes identified by women undergoing gynecologic procedures as the most important factors in their decision making. Available literature on these patient-identified priorities is then reviewed with respect to gynecologic surgery in the preoperative, intraoperative, and postoperative periods.

Results

Each section of the article concludes with Clinical Pearls, where practical tools and key elements are summarized to assist providers with incorporating these concepts into practice.

Conclusions and Relevance

Many key outcomes have been identified by women undergoing benign gynecologic surgery in their decision-making process. Patient counseling should address clinically appropriate treatment modalities and include an exploration of patient expectations and preferences around nonclinical outcomes as well. This shared decision-making model will result in improved satisfaction with outcomes.

Hysterectomy with opportunistic salpingectomy versus hysterectomy alone

BACKGROUND

Ovarian cancer has the highest mortality rate of all gynaecological malignancies with an overall five-year survival rate of 30% to 40%. In the past two decades it has become apparent and more commonly accepted that a majority of ovarian cancers originate in the fallopian tube epithelium and not from the ovary itself. This paradigm shift introduced new possibilities for ovarian cancer prevention. Salpingectomy during a hysterectomy for benign gynaecological indications (also known as opportunistic salpingectomy) might reduce the overall incidence of ovarian cancer. Aside from efficacy, safety is of utmost importance, especially due to the preventive nature of opportunistic salpingectomy. Most important are safety in the form of surgical adverse events and postoperative hormonal status. Therefore, we compared the benefits and risks of hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy.

OBJECTIVES

To assess the effect and safety of hysterectomy with opportunistic salpingectomy versus hysterectomy without salpingectomy for ovarian cancer prevention in women undergoing hysterectomy for benign gynaecological indications; outcomes of interest include the incidence of epithelial ovarian cancer, surgery-related adverse events and postoperative ovarian reserve.

SEARCH METHODS

The Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two clinical trial registers were searched in January 2019 together with reference checking and contact with study authors.

SELECTION CRITERIA

We intended to include both randomised controlled trials (RCTs) and non-RCTs that compared ovarian cancer incidence after hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications. For assessment of surgical and hormonal safety, we included RCTs that compared hysterectomy with opportunistic salpingectomy to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane. The primary review outcomes were ovarian cancer incidence, intraoperative and short-term postoperative complication rate and postoperative hormonal status. Secondary outcomes were total surgical time, estimated blood loss, conversion rate to open surgery (applicable only to laparoscopic and vaginal approaches), duration of hospital admission, menopause-related symptoms and quality of life.

MAIN RESULTS

We included seven RCTs (350 women analysed). The evidence was of very low to low quality: the main limitations being a low number of included women and surgery-related adverse events, substantial loss to follow-up and a large variety in outcome measures and timing of measurements.No studies reported ovarian cancer incidence after hysterectomy with opportunistic salpingectomy compared to hysterectomy without opportunistic salpingectomy in women undergoing hysterectomy for benign gynaecological indications. For surgery-related adverse events, there were insufficient data to assess whether there was any difference in both intraoperative (odds ratio (OR) 0.66, 95% confidence interval (CI) 0.11 to 3.94; 5 studies, 286 participants; very low-quality evidence) and short-term postoperative (OR 0.13, 95% CI 0.01 to 2.14; 3 studies, 152 participants; very low-quality evidence) complication rates between hysterectomy with opportunistic salpingectomy and hysterectomy without opportunistic salpingectomy because the number of surgery-related adverse events was very low. For postoperative hormonal status, the results were compatible with no difference, or with a reduction in anti-Müllerian hormone (AMH) that would not be clinically relevant (mean difference (MD) -0.94, 95% CI -1.89 to 0.01; I2 = 0%; 5 studies, 283 participants; low-quality evidence). A reduction in AMH would be unfavourable, but due to wide CIs, the postoperative change in AMH can still vary from a substantial decrease to even a slight increase.

AUTHORS' CONCLUSIONS

There were no eligible studies reporting on one of our primary outcomes - the incidence of ovarian cancer specifically after hysterectomy with or without opportunistic salpingectomy. However, outside the scope of this review there is a growing body of evidence for the effectiveness of opportunistic salpingectomy itself during other interventions or as a sterilisation technique, strongly suggesting a protective effect. In our meta-analyses, we found insufficient data to assess whether there was any difference in surgical adverse events, with a very low number of events in women undergoing hysterectomy with and without opportunistic salpingectomy. For postoperative hormonal status we found no evidence of a difference between the groups. The maximum difference in time to menopause, calculated from the lower limit of the 95% CI and the natural average AMH decline, would be approximately 20 months, which we consider to be not clinically relevant. However, the results should be interpreted with caution and even more so in very young women for whom a difference in postoperative hormonal status is potentially more clinically relevant. Therefore, there is a need for research on the long-term effects of opportunistic salpingectomy during hysterectomy, particularly in younger women, as results are currently limited to six months postoperatively. This limit is especially important as AMH, the most frequently used marker for ovarian reserve, recovers over the course of several months following an initial sharp decline after surgery. In light of the available evidence, addition of opportunistic salpingectomy should be discussed with each woman undergoing a hysterectomy for benign indication, with provision of a clear overview of benefits and risks.

The impact of uterine artery embolization on ovarian reserve: A systematic review and meta-analysis

INTRODUCTION

Uterine artery embolization (UAE) has been gaining increasing popularity as an effective and minimally invasive treatment for uterine fibroids. However, there has been growing concern over the risk of unintended embolization of the utero-ovarian circulation, leading to reduction of ovarian blood supply with subsequent impairment of ovarian reserve. The purpose of this study was to investigate the impact of UAE on circulating anti-Müllerian hormone (AMH) and other markers of ovarian reserve.

MATERIAL AND METHODS

This meta-analysis included all published cohort, cross-sectional and case-control studies, as well as randomized trials that investigated the impact of UAE on circulating AMH. Data sources included MEDLINE, EMBASE, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and the Cochrane Library from January 2000 to June 2019. All identified articles were screened, and articles were selected based on the inclusion and exclusion criteria. AMH and other data were extracted from the eligible articles and entered into RevMan software to calculate the weighted mean difference between pre- and post-embolization values. PROSPERO registration number: CRD42017082615.

RESULTS

This review included 3 cohort and 3 case-control studies (n = 353). The duration of follow up after UAE ranged between 3 and 12 months. Overall pooled analysis of all studies showed no significant effect of UAE on serum AMH levels (weighted mean difference -0.58 ng/mL; 95% CI -1.5 to 0.36, I²  = 95%). Subgroup analysis according to age of participants (under and over 40 years) and according to follow-up duration (3, 6 and 12 months) showed no significant change in post-embolization circulating AMH. Pooled analysis of serum follicle-stimulating hormone (FSH) concentrations (4 studies, n = 248) revealed no statistically significant change after UAE (weighted mean difference 4.32; 95% CI -0.53 to 9.17; I²  = 95%). Analysis of 2 studies (n = 62) measuring antral follicle count showed a significant decline at 3-month follow up (weighted mean difference -3.28; 95% CI -5.62 to -0.93; I²  = 94%).

CONCLUSIONS

Uterine artery embolization for uterine fibroids does not seem to affect ovarian reserve as measured by serum concentrations of AMH and FSH.

Menopausal symptoms and surgical complications after opportunistic bilateral salpingectomy, a register-based cohort study

BACKGROUND

In recent years, the fallopian tubes have been found to play a critical role in the pathogenesis of ovarian cancer. Therefore, bilateral salpingectomy at the time of hysterectomy has been proposed as a preventive procedure, but with scarce scientific evidence to support the efficiency and safety.

OBJECTIVE

Our primary objective was to evaluate the risk of surgical complications and menopausal symptoms when performing bilateral salpingectomy in addition to benign hysterectomy. Furthermore, we sought to compare time in surgery, perioperative blood loss/blood transfusion, duration of hospital stay, days to normal activities of daily living, and days out of work for hysterectomy with bilateral salpingectomy compared with hysterectomy only. A secondary objective was to study the uptake of opportunistic salpingectomy in Sweden.

STUDY DESIGN

This was a retrospective observational cohort study based on data from the National Quality Register of Gynecological Surgery in Sweden. Women <55 years of age who had a hysterectomy for benign indications with or without bilateral salpingectomy in 1998 through 2016 were included. Possible confounding was adjusted for in multivariable regression models.

RESULTS

During the study period, 23,369 women had a hysterectomy for benign indications. The frequency of bilateral salpingectomy at the time of hysterectomy increased mainly from 2013, which is why the period 2013 through mid-2016 was selected for further analysis (n = 6892). There was a low frequency of vaginal hysterectomy with bilateral salpingectomy performed in this period, which is why only abdominal and laparoscopic surgeries were selected for comparative analysis (n = 4906). This study indicates an increased risk of menopausal symptoms (adjusted relative risk, 1.33; 95% confidence interval, 1.04-1.69) 1 year after hysterectomy with bilateral salpingectomy compared with hysterectomy only. Hospital stay was 0.1 days longer in women having salpingectomy (P = .01), and bleeding was slightly reduced in the salpingectomy group (-20 mL, P = .04). Other outcome measures were not significantly associated with salpingectomy, albeit a tendency toward higher risk of minor complications was seen (adjusted relative risk, 1.30; 95% confidence interval, 0.93-1.83).

CONCLUSION

Bilateral salpingectomy at the time of hysterectomy was associated with an increased risk of menopausal symptoms 1 year after surgery. Randomized clinical trials reducing the risk of residual and unmeasured confounding and longer follow-up are needed to correctly inform women on the risks and benefits of opportunistic salpingectomy.

Hysteroscopic Placement of Platinum Microinsert in Patients With Hydrosalpinx Before In Vitro Fertilization and Embryo Transfer

OBJECTIVE

To investigate the effectiveness of Tornado and Hilal (Cook Medical, Bloomington, IN) hysteroscopic proximal tubal occlusion (HPTO) for hydrosalpinx (HX) treatment before in vitro fertilization (IVF) and embryo transfer (ET) in patients with dense pelvic adhesions or low ovarian reserve.

DESIGN

A retrospective study of patients treated between May 2014 and May 2016 (Canadian Task Force classification III).

SETTING

A university-affiliated center.

PATIENTS

One hundred fifty women with unilateral or bilateral HX who were not candidates for laparoscopic surgery.

INTERVENTION

Tornado or Hilal HPTO before IVF-ET and/or frozen ET.

MEASUREMENTS AND MAIN RESULTS

The main outcome was the cumulative live birth rate. Tornado or Hilal placement was successful for 143 (95.3%) patients. Of the 132 patients who underwent 204 ET cycles, 86 (65.2%) conceived, and 78 (59.1%) resulted in live births. The overall early and late miscarriage rates per clinical pregnancy were 12.8% and 1.1%, respectively. The ectopic pregnancy rate was 2.3%. No major complications occurred.

CONCLUSION

Tornado or Hilal HPTO is an effective alternative for treating HX before IVF-ET/frozen ET in patients with dense pelvic adhesions or low ovarian reserve.

Bilateral salpingectomy versus bilateral partial salpingectomy during cesarean delivery

Objective

To compare surgical outcomes in patients undergoing bilateral salpingectomy (salpingectomy group) with those who had partial salpingectomy (partial salpingectomy group) during cesarean delivery.

Materials and methods

A chart review from July 2015 to November 2016 was performed. We included women who had sterilization during cesarean delivery. We excluded sterilization by occlusive methods. Our primary outcomes were total operative time and a composite score of transfusion rate, internal organ injury, hospital readmission, and endometritis. Secondary outcomes included menstrual abnormalities, pelvic pain, quality of life assessment, and regrets rate. We compared these outcomes between women in the salpingectomy and partial salpingectomy groups. Chi-squared, Fisher’s exact, t-test, and Mann–Whitney U were utilized for statistical analysis where appropriate. A P<0.05 was considered significant.

Results

We included a total of 160 pregnancies. Of these, 41 were in the salpingectomy and 119 in the partial salpingectomy group. The median total operative time was longer for the salpingectomy group (62 [IQR 54, 71] vs 60 minutes [IQR 46, 72]; P=0.03). The composite of surgical complications (19.5% vs 12.6%; P=0.28) was not significantly different between our study groups. Menstrual irregularities (P≥0.99), quality of life (P≥0.99), dyspareunia (P≥0.99), dysmenorrhea (P=0.36), and regrets (P≥0.99) were not different between groups.

Conclusion

Salpingectomy during cesarean delivery increased the median operative time by 2 minutes and may not be associated with an increased risk of surgical complications. We acknowledge the need for larger multi-center trials to corroborate our outcomes.

Serum anti-Müllerian hormone concentration before and after salpingectomy for ectopic pregnancy

RESEARCH QUESTION

Does salpingectomy for ectopic pregnancy affect the ovarian reserve measured by changes in pre- and post-operative levels of anti-Müllerian hormone (AMH)?

DESIGN

This is a prospective observational multicentre study of 64 women treated with salpingectomy for an ectopic pregnancy. AMH was measured in serum samples collected at admission before salpingectomy and at follow-up (median time to follow-up [interquartile range] was 3 [3-4] months). Changes in serum AMH levels were investigated using Wilcoxon signed-rank test and the relationship between changes in AMH and age, time to follow-up, and pre-operative serum AMH level was investigated using linear regression analysis. The biological variation of AMH was also calculated.

RESULTS

Serum AMH levels did not differ significantly before and after salpingectomy (median ∆AMH [follow-up value minus admission value] 0.40 pmol/l, interquartile range -2.0 to 4.0 pmol/l). ΔAMH was independent of age, time to follow-up and pre-operative serum AMH level. The intra-individual biological variation for AMH ranged from 12.1% to 26.3%, depending on time between the two samples.

CONCLUSIONS

This is the first paired study to investigate serum AMH values before and after salpingectomy in an unselected population of women presenting with an ectopic pregnancy, including both patients who conceived naturally and following fertility treatment. It was found that salpingectomy for ectopic pregnancy had no short-term effect on serum AMH levels, and changes in AMH levels were independent of age, time to follow-up, and pre-operative serum AMH level. Furthermore, the study demonstrated a 6-month biological variation of AMH of less than 30%.

Survey of pelvic reconstructive surgeons on performance of opportunistic salpingectomy at the time of pelvic organ prolapse repair

INTRODUCTION AND HYPOTHESIS

Opportunistic salpingectomy (OS) at the time of benign hysterectomy has recently emerged as a potential primary preventive modality for ovarian cancer. Our objective was to determine whether the reported rate of OS at the time of prolapse surgery is similar to the rate of OS at the time of gynecologic surgery for non-prolapse indications.

METHODS

An anonymous online survey was sent to the Society of Gynecologic Surgery members. Responses were divided into surgeons who did and did not perform OS at the time of prolapse repair. Differences between surgeons who did and did not perform OS were evaluated using the chi-square test. Multivariable logistic regression was used to identify which responses related to increased odds of performing OS.

RESULTS

There were 117 (33.1%) completed responses; of these, 98 (83.8%) reported performing OS at the time of prolapse repair, which was similar to the reported rate of OS at the time of hysterectomy for non-prolapse indications, 82.1%. After multivariable logistic regression, performance of salpingectomy at the time of hysterectomy for a non-prolapse indication (aOR: 17.9, 95% CI: 3.11-42.01), use of a laparoscopic or robotic surgical approach (aOR 14.1, 95% CI: 1.81-32.21) and completion of an FPMRS fellowship (aOR: 3.47, 95% CI: 1.20-10.02) were associated with a higher likelihood of performing OS at the time of prolapse repair.

CONCLUSIONS

OS at the time prolapse repair is performed more frequently with concomitant hysterectomy compared with OS at the time of post-hysterectomy prolapse repair and is similar to rates of OS performed at the time of hysterectomy for non-prolapse indications.

Clinical application of serum anti-Müllerian hormone as an ovarian reserve marker: A review of recent studies

It has been more than 15 years since the measurement of serum anti-Müllerian hormone (AMH) first allowed the quantitative assessment of ovarian reserve. Meanwhile, the clinical implication of serum AMH has been expanding. The measurement of serum AMH has been applied in various clinical fields, including assisted reproduction, menopause, reproductive disorders and assessment of ovarian damage/toxicity. Well-known findings about the usefulness of serum AMH revealed by numerous studies executed in the early era include decline with aging, a good correlation with oocyte yield in assisted reproduction, upregulation in polycystic ovarian syndrome and a decrease on ovarian surgery and toxic treatment. More intensive research, including a meta-analysis, cutting-edge clinical trial and advances in AMH assays, has yielded newer findings and firmer clinical interpretations in serum AMH in the past few years. Variations in the AMH decline trajectory in the general population do not support the accurate prediction of menopause. The ability to predict pregnancy in infertility treatment and natural conception is poor, while a nomogram integrating serum AMH as a stimulation protocol is useful for avoiding poor and/or hyper-responses. On the other hand, improvements in measuring very low concentrations of serum AMH may be capable of distinguishing women with poor ovarian function. Age-independent standardization of AMH values may be helpful for comparing ovarian reserves among women at different ages.

Fertility with early reduction of ovarian reserve: the last straw that breaks the Camel's back

Diminished fertility and poor ovarian response pose a conundrum to the experts in the field of reproductive medicine. There is limited knowledge about the risk factors of diminished ovarian reserve other than the iatrogenic ones. One of the leading causes of infertility in women today is diminished ovarian reserve (DOR). DOR is characterized by a low number of eggs in a woman's ovaries and/or with poor quality of the remaining eggs, which boils down to impaired development of the existing eggs, even with assisted reproductive techniques. A good number of such women with low ovarian reserve may conceive with their own eggs, if they are given individualized treatment that is tailored for their profile. Such patients should be counseled appropriately for an aggressive approach towards achieving fertility. The sooner the treatment is started, the better the chances of pregnancy.