Desired Sterilization Procedure at the Time of Cesarean Delivery According to Insurance Status

OBJECTIVE

To evaluate whether women with Medicaid are less likely than their privately insured counterparts to receive a desired sterilization procedure at the time of cesarean delivery.

METHODS

This is a secondary analysis of a single-center retrospective cohort examining 8,654 postpartum women from 2012 to 2014, of whom 2,205 (25.5%) underwent cesarean delivery. Insurance was analyzed as Medicaid compared with private insurance. The primary outcome was sterilization at the time of cesarean delivery. Reason for sterilization noncompletion and Medicaid sterilization consent form validity were recorded. Secondary outcomes included postpartum visit attendance, outpatient postpartum sterilization, and subsequent pregnancy within 365 days of delivery.

RESULTS

Of the 481 women included in this analysis, 78 of 86 (90.7%) women with private insurance and 306 of 395 (77.4%) women with Medicaid desiring sterilization obtained sterilization at the time of cesarean delivery (relative risk 0.85, 95% CI 0.78-0.94). After multivariable logistic regression, gestational age at delivery (1.02 [1.00-1.03]), adequacy of prenatal care (1.30 [1.18-1.43]), and marital status (1.09 [1.01-1.19]) were associated with achievement of sterilization at the time of cesarean delivery. Sixty-four (66.0%) women who desired but did not receive sterilization at the time of cesarean delivery did not have valid, signed Medicaid sterilization forms, and 10 (10.3%) sterilizations were not able to be completed at the time of surgery owing to adhesions. Sterilization during cesarean delivery was not associated with less frequent postpartum visit attendance for either the Medicaid or privately insured population. Rates of outpatient postpartum sterilization were similar among those with Medicaid compared with private insurance. Among patients who did not receive sterilization at the time of delivery, 15 patients (each with Medicaid) had a subsequent pregnancy within the study period.

CONCLUSION

Women with Medicaid insurance received sterilization at the time of cesarean delivery less frequently than privately insured counterparts, most commonly due to the absence of a valid Medicaid sterilization consent form as well as adhesive disease. The constraints surrounding the Medicaid form serve as a significant barrier to achieving desired sterilization.

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

OBJECTIVES

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

Prohibiting consent: what are the costs of denying permanent contraception concurrent with abortion care?

OBJECTIVE

Oregon and federal laws prohibit giving informed consent for permanent contraception when presenting for an abortion. The primary objective of this study was to estimate the number of unintended pregnancies associated with this barrier to obtaining concurrent tubal occlusion and abortion, compared with the current policy, which limits women to obtaining interval tubal occlusion after abortion. The secondary objectives were to compare the financial costs, quality-adjusted life years, and the cost-effectiveness of these policies.

STUDY DESIGN

We designed a decision-analytic model examining a theoretical population of women who requested tubal occlusion at time of abortion. Model inputs came from the literature. We examined the primary and secondary outcomes stratified by maternal age (>30 and <30 years). A Markov model incorporated the possibility of multiple pregnancies. Sensitivity analyses were performed on all variables and a Monte Carlo simulation was conducted.

RESULTS

For every 1000 women age <30 years in Oregon who did not receive requested tubal occlusion at the time of abortion, over 5 years there would be 1274 additional unintended pregnancies and an additional $4,152,373 in direct medical costs. Allowing women to receive tubal occlusion at time of abortion was the dominant strategy. It resulted in both lower costs and greater quality-adjusted life years compared to allowing only interval tubal occlusion after abortion.

CONCLUSION

Prohibiting tubal occlusion at time of abortion resulted in an increased incidence of unintended pregnancy and increased public costs.

Reconsidering racial/ethnic differences in sterilization in the United States

OBJECTIVE

Cross-sectional studies have found that low-income and racial/ethnic minority women are more likely to use female sterilization and less likely to rely on a partner's vasectomy than women with higher incomes and whites. However, studies of pregnant and postpartum women report that racial/ethnic minorities, particularly low-income minority women, face greater barriers in obtaining a sterilization than do whites and those with higher incomes. In this paper, we address this apparent contradiction by examining the likelihood a woman gets a sterilization following each delivery, which removes from the comparison any difference in the number of births she has experienced.

STUDY DESIGN

Using the 2006-2010 National Survey of Family Growth, we fit multivariable-adjusted logistic and Cox regression models to estimate odds ratios and hazard ratios for getting a postpartum or interval sterilization, respectively, according to race/ethnicity and insurance status.

RESULTS

Women's chances of obtaining a sterilization varied by both race/ethnicity and insurance. Among women with Medicaid, whites were more likely to use female sterilization than African Americans and Latinas. Privately insured whites were more likely to rely on vasectomy than African Americans and Latinas, but among women with Medicaid-paid deliveries reliance on vasectomy was low for all racial/ethnic groups.

CONCLUSIONS

Low-income racial/ethnic minority women are less likely to undergo sterilization following delivery compared to low-income whites and privately insured women of similar parities. This could result from unique barriers to obtaining permanent contraception and could expose women to the risk of future unintended pregnancies.

IMPLICATIONS

Low-income minorities are less likely to undergo sterilization than low-income whites and privately insured minorities, which may result from barriers to obtaining permanent contraception, and exposes women to unintended pregnancies.

[Cost effects of laparoscopic and hysteroscopic female sterilization]

INTRODUCTION

The aim was to elucidate the costs and clinical results of sterilization.

MATERIAL AND METHODS

A retrospective analysis was carried out on sterilizations conducted at the Hyvinkää hospital in 2006 to 2007 by tubal ligation with clips and by microimplants.

RESULTS

Total costs obtained for microimplant sterilization per patient were 1,146 Euros and for clip sterilization 1,712 Euros. Postoperative pain was significantly less in the microimplant group, and adverse effects associated with the procedure were more common in the clip sterilization group.

CONCLUSIONS

Microimplant sterilization performed on an outpatient basis is more cost-effective than laparoscopic clip sterilization.

Toronto Health Economic and Technology Assessment (THETA) Collaborative. Hysteroscopic tubal sterilization: a health economic literature review

BACKGROUND

Hysteroscopic sterilization is a minimally invasive alternative to laparoscopic tubal ligation for women who want permanent contraception. In contrast to the laparoscopic technique, a hysteroscope is used to pass permanent microinserts through the cervix and place them in the fallopian tubes. This procedure does not require local or general anesthesia and can be performed in an office setting.

OBJECTIVES

The objective of this analysis was to determine, based on published literature, the cost-effectiveness of hysteroscopic tubal sterilization (HS) compared with laparoscopic tubal ligation (LS) for permanent female sterilization.

DATA SOURCES

A systematic literature search was conducted for studies published between January 1, 2008, and December 11, 2012.

REVIEW METHODS

Potentially relevant studies were identified based on the title and abstract. Cost-utility analyses (studies that report outcomes in terms of costs and quality-adjusted life-years) were prioritized for inclusion. When not available, cost-effectiveness, cost-benefit, and cost-consequence analyses were considered. Costing studies were considered in the absence of all other analyses.

RESULTS

A total of 33 abstracts were identified. Three cost analyses were included. A retrospective chart review from Canada found that HS was $111 less costly than LS; a prospective activity-based cost management study from Italy reported that it was €337 less costly than LS; and the results of an American decision model showed that HS was $1,178 less costly than LS.

LIMITATIONS

All studies had limited applicability to the Ontario health care system due to differences in setting, resource use, and costs.

CONCLUSIONS

Three cost analyses found that, although the HS procedure was more expensive due to the cost of the microinserts, HS was less costly than LS overall due to the shorter recovery time required.

PLAIN LANGUAGE SUMMARY

Hysteroscopic sterilization is a minimally invasive alternative to conventional tubal ligation for women who want a permanent method of contraception. Both approaches involve closing off the fallopian tubes, preventing the egg from moving down the tube and the sperm from reaching the egg. Tubal ligation is a surgical procedure to tie or seal the fallopian tubes, and it usually requires general anesthesia. In contrast, hysteroscopic tubal sterilization can be performed in 10 minutes in an office setting without general or even local anesthesia. A tiny device called a microinsert is inserted into each fallopian tube through the vagina, cervix, and uterus without surgery. An instrument called a hysteroscope allows the doctor to see inside the body for the procedure. Once the microinserts are in place, scar tissue forms around them and blocks the fallopian tubes. Health Quality Ontario commissioned a systematic review of published economic literature to determine whether hysteroscopic sterilization is cost-effective compared to tubal ligation. This review did not find any studies that reported results in terms of both costs and effectiveness or costs and quality-adjusted life-years. We did find 3 costing studies and included them in our review. All of these studies found that when hysteroscopic sterilization was performed as an outpatient procedure, it was less expensive than tubal ligation due to a shorter recovery time. However, none of the studies apply directly to Ontario because of differences in our health care system compared to those in the studies.

Hysteroscopic tubal sterilization: an evidence-based analysis

BACKGROUND

Hysteroscopic tubal sterilization is a minimally invasive alternative to laparoscopic tubal ligation for women who want permanent contraception. The procedures involves non-surgical placement of permanent microinserts into both fallopian tubes. Patients must use alternative contraception for at least 3 months postprocedure until tubal occlusion is confirmed. Compared to tubal ligation, potential advantages of the hysteroscopic procedure are that it can be performed in 10 minutes in an office setting without the use of general or even local anesthesia.

OBJECTIVE

The objective of this analysis was to determine the effectiveness and safety of hysteroscopic tubal sterilization compared with tubal ligation for permanent female sterilization.

DATA SOURCES

A standard systematic literature search was conducted for studies published from January 1, 2008, until December 11, 2012.

REVIEW METHODS

Observational studies, randomized controlled trials (RCTs), systematic reviews and meta-analyses with 1 month or more of follow-up were examined. Outcomes included failure/pregnancy rates, adverse events, and patient satisfaction.

RESULTS

No RCTs were identified. Two systematic reviews covered 22 observational studies of hysteroscopic sterilization. Only 1 (N = 93) of these 22 studies compared hysteroscopic sterilization to laparoscopic tubal ligation. Two other noncomparative case series not included in the systematic reviews were also identified. In the absence of comparative studies, data on tubal ligation were derived for this analysis from the CREST study, a large, multicentre, prospective, noncomparative observational study in the United States (GRADE low). Overall, hysteroscopic sterilization is associated with lower pregnancy rates and lower complication rates compared to tubal ligation. No deaths have been reported for hysteroscopic sterilization.

LIMITATIONS

A lack of long-term follow-up for hysteroscopic sterilization and a paucity of studies that directly compare the two procedures limit this assessment. In addition, optimal placement of the microinsert at the time of hysteroscopy varied among studies.

CONCLUSIONS

Hysteroscopic sterilization is associated with: lower pregnancy rates compared to tubal ligation (GRADE very low); lower complication rates compared to tubal ligation (GRADE very low); no significant improvement in patient satisfaction compared to tubal ligation (GRADE very low).

PLAIN LANGUAGE SUMMARY

Hysteroscopic tubal sterilization is a minimally invasive alternative to conventional tubal ligation for women who want a permanent method of contraception. Both approaches involve closing off the fallopian tubes, preventing the egg from moving down the tube and the sperm from reaching the egg. Tubal ligation is a surgical procedure to tie or seal the fallopian tubes, and it usually requires general anesthesia. In contrast, hysteroscopic tubal sterilization can be performed in 10 minutes in an office setting without general or even local anesthesia. A tiny device called a microinsert is inserted into each fallopian tube through the vagina, cervix, and uterus without surgery. An instrument called a hysteroscope allows the doctor to see inside the body for the procedure. Once the microinserts are in place, scar tissue forms around them and blocks the fallopian tubes. Health Quality Ontario conducted a review of the effectiveness and safety of hysteroscopic tubal sterilization compared to tubal ligation. This review indicates that hysteroscopic tubal sterilization is associated with: lower pregnancy rates compared to tubal ligation; lower complication rates compared to tubal ligation; no significant improvement in patient satisfaction compared to tubal ligation. However, we found a number of limitations to the studies available on hysteroscopic tubal sterilization. Among other concerns, most studies did not include long-term follow-up and only 1 study directly compared hysteroscopic tubal sterilization to tubal ligation.

Unfulfilled postpartum sterilization requests

OBJECTIVE

To determine individual and delivery characteristics of women least likely to obtain a requested postpartum tubal ligation (PPTL) and, secondarily, to compare the postpartum contraceptive choices of women with an unfulfilled sterilization request to women not requesting a PPTL.

STUDY DESIGN

Record review ofwomen delivering a liveborn singleton between December 2007 and May 2008 at the University of Texas San Antonio. Primary outcomes were risk factors for not receiving a requested PPTL. Secondary outcome was to compare the postpartum contraceptive choices of women not receiving a PPTL to controls, women not requesting a PPTL.

RESULTS

During the observation period, 429 of 1,460 women requested a PPTL; 296 (69%) received the procedure, and 133 (31%) did not. The majority of patients (332/429, 77.4%) were Hispanic. Pretest power analysis concluded that 107 women were required in each group. Cesarean delivery was associated with the highest likelihood of receiving a PPTL. Women receiving a PPTL were more likely (p < or = 0.05) to be a documented U.S. resident, married, of lower parity, have private or any medical insurance and to have received any prenatal care. Postpartum contraception among women with unfulfilled sterilization requests was similar to that among controls.

CONCLUSION

Although financial and policy barriers exist, the majority of patients requesting a PPTL received the procedure.

Copper IUD and LNG IUS compared with tubal occlusion

This article will cover current contraceptive use around the world, then examine the advantages and disadvantages of female sterilization, the hormonal intrauterine system and the copper intrauterine device. Finally, the need for contraceptive choice will be discussed along with a discussion on the cost-effectiveness of these methods.

Retrospective cost analysis comparing Essure hysteroscopic sterilization and laparoscopic bilateral tubal coagulation

STUDY OBJECTIVE

To compare the institutional cost of permanent female sterilization by Essure hysteroscopic sterilization and laparoscopic bilateral coagulation.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Midwestern academic medical center.

PATIENTS

Women of reproductive age who elected for permanent contraception by the Essure method (n = 43) or by laparoscopic tubal coagulation (n = 44) during the time frame studied.

INTERVENTIONS

Placement of the Essure inserts according to the manufacturer's instructions or laparoscopic tubal sterilization using bipolar forceps according to standard techniques of open or closed laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Cost-center data for the institutional cost of the procedure was abstracted for each patient included in the study. In addition, demographic data and procedural information were obtained and compared for the patient populations. The Essure system of hysteroscopic sterilization had a significantly decreased cost compared with laparoscopic tubal sterilization when both procedures were performed in an operating room setting. The decrease per patient in institutional cost was 180 dollars (p = .038). This included the cost of the confirmatory hysterosalpingogram 3 months after Essure placement and the cost of laparoscopic tubal occlusion by Filshie clip if the Essure micro-inserts could not be placed. The majority of the cost was related to hospital costs as opposed to physician costs. The Essure procedure had higher costs for disposable equipment (p <.0001), but this was offset by higher charges for operating room costs, which included the recovery room (p <.0001) and pharmacy costs (p <.0001) in the patients in the laparoscopy group.

CONCLUSION

In our setting, the Essure hysteroscopic sterilization had significant cost savings compared with laparoscopic tubal sterilization (p = .038). We believe that our data represent the minimum of potential savings using this approach, and future developments will only increase the cost difference found in our study.

Utility and diagnostic accuracy of fallopian tube touch imprint cytology

OBJECTIVE

To determine the diagnostic accuracy of cytology smears in distinguishing between tube and non-tube structures.

METHODS

One hundred cytology smears of fallopian tube and non-tube structures (vessels, round and ovarian ligaments) were prepared from surgically removed uterus and fallopian tube specimens and stained by the Papanicolaou method. The slides were reviewed blindly by pathologists and interpreted as tube or non-tube structures. The results were compared to the histological examination of the same specimens.

FINDINGS

Results indicated an overall accuracy of 97% with a specificity of 98% and sensitivity of 96% for cytology smears, taking histology as the gold standard. Positive and negative predictive values were 96.1% and 97.9%, respectively.

CONCLUSION

Cytology smears are a convenient and cost effective tool for laboratory confirmation of tubal sterilization. This method can reduce the costs of laboratory examination, especially in developing countries, where tubal sterilizations are done in large cohorts. However, histological slides remain the gold standard in cases of medicolegal problems.

Office hysteroscopic sterilization compared with laparoscopic sterilization: A critical cost analysis

STUDY OBJECTIVE

To evaluate the actual cost difference in performing Essure hysteroscopic sterilization in the office compared with ambulatory surgery using laparoscopic sterilization in the operating room.

DESIGN

Cost-comparison analysis (Canadian Task Force classification III).

SETTING

University hospital and affiliated outpatient office.

INTERVENTIONS

Hysteroscopic placement of Essure device in an office setting and laparoscopic tubal ligation for permanent sterilization.

MEASUREMENTS AND MAIN RESULTS

The various costs associated with the two procedures at our institution were compiled, and a direct cost comparison was made. We used actual institutional costs of the procedures, not billing or reimbursement. We found laparoscopic tubal ligations to cost 3449 dollars compared with hysteroscopic placement of the Essure device that costs 1374 dollars yielding a 2075 dollars difference between the procedures.

CONCLUSION

In our institution and in our experience, office-hysteroscopic placement of the Essure device is a more cost-effective method than laparoscopic tubal ligation.

Cost analysis of tubal anastomosis by laparoscopy and by laparotomy

STUDY OBJECTIVE

To compare the costs of tubal anastomosis performed by laparoscopy and by laparotomy.

DESIGN

Cost analysis study using the hospital administrative database (Canadian Task Force classification II-2).

SETTING

University teaching hospital.

PATIENTS

Eighty-nine women. Intervention. Tubal anastomosis by laparoscopy (43) and by laparotomy (46).

MEASUREMENTS AND MAIN RESULTS

Tubal anastomosis took longer when performed by laparoscopy than by laparotomy; however, the total time patients spent in the operating room was similar. Women treated by laparoscopy spent more time in the recovery room. Labor costs for nurses in the operating room and recovery room costs were significantly higher in the laparoscopy group. Costs for operating room supplies were similar. Pharmacy costs and expenses in the ward were lower in the laparoscopy group. The mean total cost for laparoscopic tubal anastomosis was $861 +/- 137 and for laparotomy was $1348 +/- 188 (p <0.001).

CONCLUSION

Laparoscopic tubal anastomosis costs less than tubal anastomosis by laparotomy.

Assessing the cost-effectiveness of contraceptive methods in Shiraz, Islamic Republic of Iran

To determine the cost-effectiveness of seven contraceptive methods from the providers' perspective, the cost per adjusted couple-years of protection (ACYP) was calculated for each method based on region-specific conversion factors. More than 74,800 ACYPs were provided during March 1999 to February 2000. Intrauterine devices and implants offered the highest and lowest ACYP respectively. Condom was the single most expensive contraceptive method. Vasectomy was the most cost-effective method and implant provided the highest cost per ACYP.

Economic and clinical outcomes of microlaparoscopic and standard laparoscopic sterilization. A comparison

OBJECTIVE

To compare micro-laparoscopic surgical sterilization and standard laparoscopic sterilization with respect to cost effectiveness and patient preferences.

STUDY DESIGN

A retrospective study of all laparoscopic surgical sterilizations performed under general anesthesia at Johns Hopkins Bayview Medical Center--16 micro-laparoscopies and 34 standard laparoscopies. Cases selected for review were limited to patients undergoing surgical contraception and not requiring additional, concurrent procedures. Laparoscopic surgical sterilization was performed using a double-puncture technique with silicone band application. In each case either a standard, 10-mm laparoscope or a 2-mm micro-laparoscope was used, and the procedure was performed under general anesthesia. Postoperative pain management was achieved by nonsteroidal antiinflammatory drugs and/or narcotic analgesia. All cases were performed by residents under faculty supervision. Medical records and hospital billing records were reviewed, and a standardized telephone interview was conducted to assess postoperative quality of life and patient satisfaction.

RESULTS

Both techniques were comparable in cost effectiveness. There was no significant difference in operating room time, average operating room costs, average ancillary department costs, instrument and supply costs, or length of stay. Postoperative discomfort was significantly less with microlaparoscopy (P = .05), and patient satisfaction was higher in the microlaparoscopy group.

CONCLUSION

Microlaparoscopy and the standard laparoscopic approach for surgical sterilization are associated with similar hospital charges. Postoperative pain and overall patient satisfaction were significantly better with microlaparoscopy than standard laparoscopy.

Sterilization and its consequences

The purpose of this review is to analyze critically the two techniques of sterilization (bilateral tubal ligation [BTL] and vasectomy) so that a physician may provide informed consent about methods of sterilization. A MEDLINE search and extensive review of published literature dating back to 1966 was undertaken to compare preoperative counseling, operative procedures, postoperative complications, procedure-related costs, psychosocial consequences, and feasibility of reversal between BTL and a vasectomy. Compared with a vasectomy, BTL is 20 times more likely to have major complications, 10 to 37 times more likely to fail, and cost three times as much. Moreover, the procedure-related mortality, although rare, is 12 times higher with sterilization of the woman than of the man. Despite these advantages, 300,000 more BTLs were done in 1987 than vasectomies. In 1987, there were 976,000 sterilizations (65 percent BTLs and 35 percent vasectomies) with an overall cost of $1.8 billion. Over $260 million could have been saved if equal numbers of vasectomies and BTLs had been performed, or more than $800 million if 80 percent had been vasectomies, as was the case in 1971. The safest, most efficacious, and least expensive method of sterilization is vasectomy. For these reasons, physicians should recommend vasectomy when providing counseling on sterilization, despite the popularity of BTL.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to predict the failure rates and likelihood of successful reversal of tubal ligation and vasectomy; to recall the difference in cost between the two sterilization procedures, and to describe the short-term and long-term complications associated with each of the two methods of sterilization.

Modified minilaparotomy technique of interval female sterilization

The study of a modified minilaparotomy technique of interval female sterilization is reported. The modified minilaparotomy technique of interval female sterilization is performed under local anesthesia using the Ramathibodi uterine manipulator, bivalve speculum, and a low midline incision. Sixty cases were treated with this technique. From the study, it was revealed that the mean age of patients +/- SD was 31.2 +/- 5.6 years, the mean body weight +/- SD was 43.3 +/- 5.1 kg, and the mean height +/- SD was 152.1 +/- 8.2 cm. The mean operating time was 24.3 +/- 5.5 min with a range from 15 to 35 min. All patients recovered and were allowed home within 2 h after operation. No immediate or late complications were observed. It was concluded that this technique is quick, safe, inexpensive, and easy to perform as an outpatient procedure.

A comprehensive and efficient process for counseling patients desiring sterilization

To optimize the time spent counseling a sterilization patient, this article presents a 10-step process that includes all steps necessary to ensure a comprehensive counseling session: (1) Discuss current contraception use and all available methods; (2) assess the client's interest in/readiness for sterilization; (3) emphasize that the procedure is meant to be permanent, but there is a possibility of failure; (4) explain the surgical procedure using visuals, and include a discussion of benefits and risks; (5) explain privately to the client the need to use condoms if engaging in risky sexual activity; (6) have the client read and sign an informed consent form; (7) schedule an appointment for the procedure and provide the patient with a copy of all necessary paperwork; (8) discuss cost and payment method; (9) provide written preoperative and postoperative instructions; and (10) schedule a postoperation visit, or a postoperation semen analysis.

A comparison of the cost of local versus general anesthesia for laparoscopic sterilization in an operating room setting

OBJECTIVE

To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance.

DESIGN

A retrospective review of charges.

SETTING

The Regional Medical Center, Memphis, Tennessee.

PATIENTS

Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization.

MEASUREMENTS AND MAIN RESULTS

Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment.

CONCLUSION

Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.

Hysteroscopic sterilization

Despite the numerous painstaking evaluative trials that were conducted for more than two decades, hysteroscopic sterilization techniques remain more of a concept than a reality. However, it is likely that transcervical methods will continue to attract the investigator who is interested in simple, inexpensive outpatient office or female sterilization procedures in the clinic. Regardless, the cost of clinical trials, required follow-up, and preclinical toxicologic evaluations may continue to inhibit further research in this area.

Twenty-two years of office and outpatient laparoscopy: current techniques and why I chose them

Since 1972 I have introduced the following technical modifications in outpatient laparoscopy under local anesthesia to improve safety, economy, and patient acceptability: avoiding the insufflating needle and sharp trocar in favor of open abdominal entry, using the Hasson cannula; introducing room air for insufflation instead of nitrous oxide or carbon dioxide; using the Hulka clip in place of tubal coagulation; making a single-incision, open surgical entry through the central umbilical fossa in obese patients; and completing fascial penetration with a blunt hemostat or Kelly clamp to minimize the risk of bowel or vessel injury.

Cost-effectiveness of levonorgestrel subdermal implants. Comparison with other contraceptive methods available in the United States

The objective of this analysis was to evaluate and compare the cost-effectiveness of eight contraceptive methods: condoms, diaphragms, oral contraceptives, intrauterine devices, medroxyprogesterone acetate suspension, levonorgestrel subdermal implants, tubal ligation and vasectomy. Based on a comprehensive review of the literature and various additional data sources, this analysis identified, measured and compared direct costs of the methods, physician visits, treatment of adverse effects and cost of failure (i.e., mean cost for all types of deliveries or first-trimester abortion). Medical benefits (if any) resulting from each contraceptive method were calculated and considered in the analysis as cost savings. The cost of method failure proved to be the greatest influence on cost-effectiveness. Sterilization was identified as the most cost-effective method overall. Of the reversible methods, the intrauterine device was found to be the most cost-effective, followed by levonorgestrel implants.

Low-cost office laparoscopic sterilization

Between September 1986 and February 1992 we performed 210 laparoscopic tubal ligations in our office under local anesthesia using the Hulka clip. During the last 2 years we used a microchip video camera and endocoagulated the fallopian tubes adjacent to the clip in 84 women. The length of time for each procedure ranged from 15 to 30 minutes (average 20 min). There were no intraoperative complications. Failure to tolerate abdominal lifting (the "belly" test) was the only contraindication in this series. Previous abdominal surgery was not a contraindication. The three known failures in our first 69 cases were thought to be inaccurate clip applications. Subsequently, we added endocoagulation to the technique. Our procedure is cost efficient and time saving for both patients and physicians.

Female sterilization by the vaginal route: a positive reassessment and comparison of 4 tubal occlusion methods

Over the last 15 years female sterilization by the vaginal route has been abandoned in favour of the abdominal approach via a laparoscope or a suprapubic incision. This was justified when the vaginal route was used for a fimbriectomy or a Pomeroy type of sterilization. The use of tubal occlusion methods designed for the laparoscope has simplified the technique of vaginal sterilization and lowered the morbidity. Four hundred and ninety consecutive cases over an 18-year period are reviewed. Four hundred and eighty five were completed vaginally. The methods used were Pomeroy with catgut, Falope ring, Hulka and Filshie clips. The Filshie clip was the most satisfactory. Vaginal sterilization is suitable for day care. The readmission rate was 1%. There was no case of pelvic infection in 177 clip cases but 5 in 173 where the Pomeroy technique was used. The pregnancy rate was highest with the Hulka clip. The overall rate was 1%. With clip methods strong analgesics were only required in 6% postoperatively and only 14% took any analgesic after returning home; consequently return to normal activities was rapid. The patient's weight was not related to operative difficulty when clips were used so the vaginal route may prove to be the method of choice in the obese. Filshie clip sterilization via the posterior fornix of the vagina could be the most cost-effective method of sterilization available at present. The vaginal route needs reappraisal using contemporary methods of tubal occlusion.

[Ambulatory laparoscopic sterilization--should local analgesia and intravenous sedation replace general anesthesia? A comparative clinical trial]

A prospective, randomized study comprised 125 outpatient laparoscopic sterilization patients who had received either general anaesthesia or local anaesthesia together with intravenous sedation. The patients who had received local anaesthesia suffered significantly less postoperative pain and sore throat. Recovery and discharge were similar in the two groups, but those given a general anaesthetic were more drowsy in the evening on the day of operation. The time spent in the operating theatre was significantly shorter for the group given local anaesthesia, and the costs were lower. The majority of patients from both groups would prefer local anaesthesia and sedation for a similar procedure in the future. We conclude that local anaesthesia by intravenous sedation is the method of choice for laparoscopic sterilization.

Prohibition of preventive health care: an analysis of Medicaid non-reimbursement for indigent women

This paper presents a policy analysis of the impact of prohibiting Medicaid reimbursement funding for tubal ligations by indigent women, under 21 years of age. Because this population is dependent upon Medicaid funds, the freedom of self determination is limited. The current policy does not provide any alternative to the age rule, even if the patient is infected with a life-threatening disease, such as human immunodeficiency virus (HIV). The policy, therefore, creates serious problems for those individuals who choose to prevent a pregnancy under certain life-threatening circumstances. As the incidence of AIDS continues to increase, the absence of an age alternative for tubal ligations will become a problem of increasing practical and statistical significance. The conceptual framework for the analysis of Medicaid nonreimbursement for tubal ligations, with respect to age demands was adopted from the work of Gilbert and Specht, 1986. Four dimensions of choice are addressed: (1) the bases of social allocation, (2) the nature/type of social provisions, (3) the delivery system and (4) finances. Although all areas will be addressed, the major emphasis will be placed on social allocation.

Government-funding program on reversal of tubal sterilization

Three hundred and sixty-one women were provided government-funded sterilization reversal services with the technique of microsurgery. A large majority of reasons (89.8%) for requesting reversal surgery was a loss of children, and the mean interval between sterilization and reversal was 28.7 months. Two hundred and seven (69.7%) of 297 follow-up cases have experienced term delivery or intra-uterine pregnancy and 5 cases were ectopic pregnancy. The largest number of reversal clients (63.3%) were sterilized by the laparoscopic unipolar coagulation technique and the next largest group (24.2%) was sterilized by the laparoscopic banding technique. The highest pregnancy rate (77.8%) was shown in clients who had undergone laparoscopic banding technique while the lowest (65.9%) was the group of laparoscopic unipolar coagulation. A more than 60% of the clients became pregnant within 6 months of their reversal surgery, with the shortest interval being 1 month, the longest 39 months, and the mean 7.6 months. A large majority of the successful cases, 81.6%, were pregnant within 1 year of their reversal surgery.

[Laparoscopic sterilization of women by electrocoagulation. A 5-year material]

A retrospective questionnaire investigation was undertaken involving 253 women who had been sterilized by electrocoagulation in a small department of general surgery during a five-year period. This revealed a frequency of pregnancy of 1.6% following a total period of observation averaging 42 months. The average age of the women in this material was 35.8 years and these had, on an average, 2.8 children. 4.0% regretted the intervention. The majority of the women (97.0%) would choose laparoscopic sterilization as the method of contraception today, if they should choose again. The per- and postoperative frequency of complications was 4.3%. The operating time was 33.8 minutes on an average and the duration of postoperative hospitalization was 1.5 days on an average. On a average, the patients felt well after 7.9 days and they resumed sexual activities after an average of 16.7 days. The conclusion of this investigation is that laparoscopic sterilization by electrocoagulation carried out by an experienced surgeon in a small department for general surgery is a safe and cheap method of sterilization which is reasonably free from complications for the patients.

Sterilization: Canadian choices

Significant differences in cost and safety between vasectomy and tubal ligation have been reported. For this reason the incidence of these two procedures between 1976 and 1986 was studied to obtain information upon which future policy decisions might be based. Although tubal ligation predominated in almost every province and year its rate declined by 27.6% over the study period, whereas the rate of vasectomy increased by 39.1%. When projected to 1988 the national rates for the two procedures became nearly equal; those for Quebec had become equal by 1986. Provincial differences were most marked in eastern Canada, where neighbouring provinces had the highest and the lowest rates of sterilization in the country. Given the relative economic and surgical disadvantages of tubal ligation, policymakers may wish to consider fostering an increased acceptance of vasectomy, particularly in areas where such acceptance continues to be slow.

Comparative risks and costs of male and female sterilization

Couples who are considering elective sterilization should compare the risks and costs of male and female sterilization procedures as part of the decision process. Morbidity, mortality, failure rates, and short-term costs associated with male and female sterilization procedures were estimated from data available in previous case series. Male sterilization procedures were found to have zero attributable deaths and significantly less major complications when compared to female sterilization procedures. No less than 14 deaths a year can be attributed to female sterilization procedures in the US. Male and female sterilization procedures have efficacy rates that are not significantly different from each other. The short-term costs of female sterilization are 3.0 to 4.1 times that of vasectomy.

Tubal sterilizations performed in freestanding, ambulatory-care surgical facilities in the United States in 1980

In 1981 the American Association of Gynecologic Laparoscopists and the Division of Reproductive Health, Centers for Disease Control, jointly conducted a study of tubal sterilizations performed in 141 freestanding, ambulatory-care surgical facilities in 1980 in the United States. Information was collected through mailed questionnaires and telephone interviews. Of 330 potential responding facilities, 141 we identified as freestanding, ambulatory-care surgical facilities. About 16,500 tubal sterilizations were performed in these facilities in 1980. The mean number of tubal sterilizations per freestanding, ambulatory-care surgical facility was 212. Sixty-seven percent of tubal sterilizations were performed in the south and west. General anesthesia was the anesthetic method used in 97% of the procedures. Nearly 91% of tubal sterilizations were done via laparoscopy, with bipolar electrocoagulation the tubal-occlusion method used most frequently. After tubal sterilization the patients were observed for an average of 2.4 hours before discharge. The average cost of laparoscopic tubal sterilization was $801; for nonlaparoscopic tubal sterilization it was $850.

[Interval Falope ring sterilization in the Cape Province: experience with 9175 cases over 4 years]

During a 4-year period 9175 women were sterilized under local anaesthesia by the laparoscopic Falope ring method. These procedures were performed in smaller towns in the Cape Province. The method used, its cost-effectiveness, and its acceptability to patients are described in detail. This venture proves convincingly that a highly sophisticated medical service can be made available to rural areas, ensuring greater support for a high-priority primary health care service.

The impact of laparoscopy on tubal sterilization in United States hospitals, 1970 and 1975 to 1978

During the 1970s, tubal sterilization became an important method of fertility control in the United States. Over the same period laparoscopy emerged as an important innovation, one that has been associated with both a shift from postpartum to interval sterilization and a dramatic decrease in length of hospital stay required for sterilization. The use of laparoscopy has also been associated with an increase in hospital-based outpatient sterilization, particularly in the West. The number of sterilizations performed in hospitals and the use of laparoscopy for interval sterilization in hospitals both appear to have peaked. The laparoscope is an example of a technologic advance that has reduced medical care costs.

The use of the laparoscope in rural Thailand

A survey of the use of laparoscopy in rural Thailand was undertaken between June 1974 and December 1977. All the physicians were trained at either Ramathibodi Hospital, Bangkok, or The Johns Hopkins Program for International Education in Gynecology and Obstetrics and the USA; about 30% and 46% of the physicians, respectively, were endoscopically inactive. The complication rate of rural laparoscopy was high and was inversely proportional to the degree of utilization. It is concluded that for a developing country with limited resources, laparoscopic sterilization in rural areas is not cost-effective; a technique using simpler and hardier equipment should be chosen.

Advances in sterilization equipment

From the array of sterilization procedures that are safe, simple and effective, the service provider must select procedures that fit his or her logistical criteria, which include the cost and maintenance of equipment, availability of supplies, and training of the requisite personnel. In this paper, these criteria are discussed for each of the various sterilization procedures. Information about female sterilization equipment for conventional postpartum laparotomy, minilaparotomy, colpotomy, laparoscopy, and culdoscopy is presented, together with facts about the related tubal occlusion techniques. The standard ligation techniques for male sterilization are compared with the newer electrocoagulation and thermocoagulation methods. A variety of methods for both female and male sterilization that are in the research stage are also mentioned. It is concluded that, from a programmatic point of view, vasectomy and postpartum ligation via laparotomy are the optimal sterilization procedures. For women who have not recently been pregnant, minilaparotomy with a standard tubal ligation technique is recommended, except in large teaching hospitals where laparoscopy can be performed efficiently.