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Contraception UPDATE CONTRACEPTION Adopting the “opportunistic salpingectomy philosophy” for benign hysterectomies has been fairly easy for ObGyns, but what about for permanent contraception? Is it time to advocate for this global practice? ❯❯ Melissa C. Matulich, MD, is a Family Planning ❯❯ Mitchell D. Creinin, MD, is Professor and Director Fellow in the Department of Obstetrics and of Family Planning in the Department of Obstetrics Gynecology at the University of California–Davis, and Gynecology at the University of California–Davis. Sacramento, California. Dr. Matulich reports no financial relationships relevant to this article. Dr. Creinin receives speaking honoraria from Al- lergan and Merck & Co., serves on an Advisory Board for Merck & Co. and is a consultant for Estetra, Health Decisions, and Medicines360. The Department of Obstetrics and Gynecology, University of California, Davis, receives research funding for contraceptive clinical trials from Contramed, Medicines360, Merck & Co., National Institutes of Health/Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Society of Family Planning. • ccording to the most recent data (2011– being the primary goals of the procedure.5 A 2013), 62% of women of childbearing age Accordingly, rapid occlusive procedures were (15–44 years) use some method of contracep- commonplace. However, advancement of IN THIS tion. Of these “contracepting” women, about laparoscopic technology related to insuffla- ARTICLE 25% reported relying on permanent contra- tion systems, surgical equipment, and video ception, making it one of the most common capabilities did not change this practice. Total salpingectomy methods of contraception used by women Recent literature has suggested that com- at delivery in the United States (FIGURE 1, page 18).1,2 plete fallopian tube removal provides addi- page 18 Women either can choose to have a perma- tional benefits. With increasing knowledge nent contraception procedure performed about the origin of ovarian cancer, as well as immediately postpartum, which occurs after increasing data to support the hypothesis that Interval permanent approximately 9% of all hospital deliveries in complete tubal excision results in increased contraception the United States,3 or at a time separate from ovarian cancer protection when compared page 22 pregnancy. with occlusive or partial salpingectomies, The most common methods of perma- both the American College of Obstetricians Tube removal and 6 nent contraception include partial salpin- and Gynecologists (ACOG) and the Society ovarian reserve 7 gectomy at the time of cesarean delivery or of Gynecologic Oncology (SGO) recommend page 23 within 24 hours after vaginal delivery and discussing bilateral total salpingectomy with laparoscopic occlusive procedures at a time patients desiring permanent contraception. unrelated to the postpartum period.3 Hystero- Although occlusive procedures decrease a scopic occlusion of the tubal ostia is a newer woman’s lifetime risk of ovarian cancer by 24% option, introduced in 2002; its worldwide use to 34%,8,9 total salpingectomy likely reduces is concentrated in the United States, which this risk by 49% to 65%.10,11 accounts for 80% of sales based on revenue.4 With this new evidence, McAlpine and Historically, for procedures remote colleagues initiated an educational cam- from pregnancy, the laparoscopic approach paign, targeting all ObGyns in British Colum- evolved with less sophisticated laparo- bia, which outlined the role of the fallopian scopic equipment and limited visualiza- tube in ovarian cancer and urged the consid- tion, which resulted in efficiency and safety eration of total salpingectomy for permanent obgmanagement.com Vol. 29 No. 8 | August 2017 | OBG Management 17 UPDATE contraception FIGURE 1 Percent distribution of contraception in place of occlusive or partial contracepting women by type of method: salpingectomy procedures. They found that United States, 2011–20131,2 this one-time targeted education increased the use of total salpingectomy for permanent contraception from 0.5% at 2 years before the intervention to 33.3% by 2 years afterwards.12 On average, laparoscopic bilateral salpin- Implant 1.3% gectomy took 10 minutes longer to complete than occlusive procedures. Most impor- Injectable Othera tantly, they found no significant differences 4.5% 9.4% in complication rates, including hospital readmissions or blood transfusions. Male Oral Although our community can be permanent 25.9% contraception applauded for the rapid uptake of concomi- 8.2% tant bilateral salpingectomy at the time of benign hysterectomy,12,13 offering total sal- Intrauterine pingectomy for permanent contraception is device far from common practice. Similarly, while 10.3% Female permanent multiple studies have been published to sup- Male contraception port the practice of opportunistic salpingec- condom 25.1% tomy at the time of hysterectomy, little has 15.3% been published about the use of bilateral salpingectomy for permanent contraception until this past year. In this article, we review some of the first publications to focus specifically on the fea- sibility and safety profile of performing either immediate postpartum total salpingectomy aOther includes withdrawal (4.8%), hormonal ring or patch (2.6%), and “other” (2.0%). or interval total salpingectomy in women desiring permanent contraception. Stop using the term “sterilization” Family Planning experts are now strongly discouraging could simultaneously defend public health, preserve precious the use of terms like “sterilization,” “permanent fiscal resources, and mitigate menace of the “unfit and sterilization,” and “tubal ligation” due to sterilization feebleminded.” The US eugenics movement even inspired abuses that affected vulnerable and marginalized Hitler and the Nazi eugenics movement in Germany. populations in the United States during the early- to mid- Because of these reproductive rights atrocities, a 20th century. large counter movement to protect the rights of women, In 1907, Indiana was the first state to enact a eugenics- men, and children resulted in the creation of the Medicaid based permanent sterilization law, which initiated an permanent sterilization consents that we still use today. aggressive eugenics movement across the United States. Although some experts question whether the current This movement lasted for approximately 70 years and Medicaid protective policy should be reevaluated, many resulted in the sterilization of more than 60,000 women, men, are focused on the use of less offensive language when and children against their will or without their knowledge. discussing the topic. One of the major contributors to this movement was the Current recommendations are to use the phrase state of California, which sterilized more than 20,000 women, “permanent contraception” or simply refer to the procedure men, and children. name (salpingectomy, vasectomy, tubal occlusion, etc.) to They defined sterilization as a prophylactic measure that move away from the connection to the eugenics movement. 18 OBG Management | August 2017 | Vol. 29 No. 8 obgmanagement.com Total salpingectomy: A viable option for permanent contraception after vaginal or at cesarean delivery Shinar S, Blecher Y, Alpern S, et al. Total bilateral sal- and was found to have hemoperitoneum pingectomy versus partial bilateral salpingectomy for requiring exploratory laparotomy. Signifi- permanent sterilization during cesarean delivery. Arch cant bleeding from the bilateral mesosal- Gynecol Obstet. 2017;295(5):1185–1189. pinges was discovered, presumably directly related to the total salpingectomy. Danis RB, Della Badia CR, Richard SD. Postpartum permanent sterilization: could bilateral salpingectomy replace bilateral tubal ligation? J Minim Invasive Gy- Details of Danis et al necol. 2016;23(6):928–932. Intuitively, performing salpingectomy at the time of cesarean delivery does not seem as significant a change in practice as would hinar and colleagues presented a ret- performing salpingectomy through a small Srospective case series that included periumbilical incision after vaginal deliv- women undergoing permanent contracep- ery. However, Danis and colleagues did just tion procedures during cesarean delivery at that; they published a retrospective case a single tertiary medical center. The authors series of total salpingectomy performed evaluated outcomes before and after a global within 24 hours after a vaginal delivery at an hospital policy changed the preferred per- urban, academic institution. They included manent contraception procedure from par- all women admitted for full-term vaginal Minimal operative tial to total salpingectomy. deliveries who desired permanent contra- time differences ception, with no exclusion criteria related between total to body mass index (BMI). The authors and partial Details of the Shinar technique reported on 80 women, including 64 (80%) salpingectomy and outcomes who underwent partial salpingectomy via were found in Of the 149 women included, 99 under- the modified Pomeroy or Parkland tech- both case series went partial salpingectomy via the modi- nique and 16 (20%) who underwent total fied Pomeroy technique and 50 underwent salpingectomy. Most women had a BMI total salpingectomy using an electrothermal of less than 30 kg/m2; less than 15% of the bipolar tissue-sealing instrument (Ligasure). women in each group had a BMI greater The authors found no difference in opera- than 40 kg/m2. tive times and similar
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