Total salpingectomy: A viable option for permanent contraception after vaginal or at cesarean delivery
Shinar S, Blecher Y, Alpern S, et al. Total bilateral salpingectomy versus partial bilateral salpingectomy for permanent sterilization during cesarean delivery. Arch Gynecol Obstet. 2017;295(5):1185-1189.
Danis RB, Della Badia CR, Richard SD. Postpartum permanent sterilization: could bilateral salpingectomy replace bilateral tubal ligation? J Minim Invasive Gynecol. 2016;23(6):928-932.
Shinar and colleagues presented a retrospective case series that included women undergoing permanent contraception procedures during cesarean delivery at a single tertiary medical center. The authors evaluated outcomes before and after a global hospital policy changed the preferred permanent contraception procedure from partial to total salpingectomy.
Details of the Shinar technique and outcomes
Of the 149 women included, 99 underwent partial salpingectomy via the modified Pomeroy technique and 50 underwent total salpingectomy using an electrothermal bipolar tissue-sealing instrument (Ligasure). The authors found no difference in operative times and similar rates of complications. Composite adverse outcomes, defined as surgery duration greater than 45 minutes, hemoglobin decline greater than 1.2 g/dL, need for blood transfusion, prolonged hospitalization, ICU admission, or re-laparotomy, were comparable and were reported as 30.3% and 36.0% in the partial and total salpingectomy groups, respectively, (P = .57).One major complication occurred in the total salpingectomy cohort; postoperatively the patient had hemodynamic instability and was found to have hemoperitoneum requiring exploratory laparotomy. Significant bleeding from the bilateral mesosalpinges was discovered, presumably directly related to the total salpingectomy.
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Hysteroscopic tubal occlusion: How new product labeling can be a resource for patient counseling
Details of Danis et al
Intuitively, performing salpingectomy at the time of cesarean delivery does not seem as significant a change in practice as would performing salpingectomy through a small periumbilical incision after vaginal delivery. However, Danis and colleagues did just that; they published a retrospective case series of total salpingectomy performed within 24 hours after a vaginal delivery at an urban, academic institution. They included all women admitted for full-term vaginal deliveries who desired permanent contraception, with no exclusion criteria related to body mass index (BMI). The authors reported on 80 women, including 64 (80%) who underwent partial salpingectomy via the modified Pomeroy or Parkland technique and 16 (20%) who underwent total salpingectomy. Most women had a BMI of less than 30 kg/m2; less than 15% of the women in each group had a BMI greater than 40 kg/m2.
The technique for total salpingectomy involved a 2- to 3-cm vertical incision at the level of the umbilicus, elevation of the entire fallopian tube with 2 Babcock clamps, followed by the development of 2 to 3 windows with monopolar electrocautery in the mesosalpinx and subsequent suture ligation with polyglactin 910 (Vicryl, Ethicon).
Major findings included slightly longer operative time in the total salpingectomy compared with the partial salpingectomy group (a finding consistent with other studies12,14,15) and no difference in complication rates. The average (SD) surgical time in the partial salpingectomy group was 59 (16) minutes, compared with 71 (6) minutes in the total salpingectomy group (P = .003). The authors reported 4 (6.3%) complications in the partial salpingectomy group--ileus, excessive bleeding from mesosalpinx, and incisional site hematoma--and no complications in the total salpingectomy group (P = .58).
WHAT THIS EVIDENCE MEANS FOR PRACTICE
These 2 studies, although small retrospective case series, demonstrate the feasibility of performing total salpingectomies with minimal operative time differences when compared with more traditional partial salpingectomy procedures. The re-laparotomy complication noted in the Shinar series cannot be dismissed, as this is a major morbidity, but it also should not dictate the conversation.
Overall, the need for blood transfusion or unintended major surgery after permanent contraception procedures is rare. In the U.S. Collaborative Review of Sterilization study, none of the 282 women who had a permanent contraception procedure performed via laparotomy experienced either of these outcomes.16 Only 1 of the 9,475 women (0.01%) having a laparoscopic procedure in this study required blood transfusion and 14 (0.15%) required reoperation secondary to a procedure complication.17 The complication reported in the Shinar study reminds us that the technique for salpingectomy in the postpartum period, whether partial or total, should be considered carefully, being mindful of the anatomical changes that occur in pregnancy.
While larger studies should be performed to confirm these initial findings, these 2 articles provide the reassurance that many providers may need before beginning to offer total salpingectomy procedures in the immediate postpartum period.
Our contraceptive counseling philosophy: The shared decision-making model
When women present for permanent contraception counseling, we must remember that our patients' needs are often far too diverse and dynamic to allow a universal counseling technique. Every provider likely has a counseling style, with a structure and language that has been altered and changed through years of practice, patient experiences, and new scientific technologies and data. Unfortunately, provider biases and past coercive practices also influence contraceptive counseling.
Historically, some providers used formulas related to a woman's age and parity to decide if she could have a permanent contraception procedure, possibly based on fears of patient regret. Such practices are an embarrassment to the principles of patient autonomy and empowerment, which should serve as the foundation for any contraceptive conversation. Studies of regret after permanent contraception procedures are often misinterpreted; although younger women experience higher rates of regret, the absolute rate still favors performing the procedure.1,2 When comparing women aged 30 or younger to those older than 30 years at the time of procedure, the vast majority (about 80%) of those 30 and younger do not express regret.1 Less than 5% of women who express regret access a reversal procedure.2,3 Our job as providers is to educate and allow women to understand the options--and with permanent contraception that also means explaining the potential for regret; however, empowering women does not mean limiting an opportunity for the majority to potentially impact the minority.
Our contraceptive counseling philosophy follows the shared decision-making model. This model informs the patient, tailors the conversation toward her priorities, and maintains patient autonomy, while empowering the patient to take control of her reproductive health and future. When a patient expresses the desire for permanent contraception, we ensure she understands the permanence of the procedure and offer information about other Tier 1 contraceptive options, including long-acting reversible methods and vasectomy. We use the evidence-based World Health Organization counseling table4,5 to assist with the discussion and provide vasectomy referral and further information about specific intrauterine devices or the contraceptive implant based on the woman's interests.
For women who desire a female permanent contraception procedure, we also provide information tables comparing laparoscopic tubal occlusion procedures, laparoscopic bilateral salpingectomy, and hysteroscopic tubal occlusion. These tables review how each procedure is performed; risks and benefits, including failure rates over time; and ovarian cancer protection estimates. Our office also has devised tables to inform women seeking permanent contraception immediately after delivery and unrelated to pregnancy. Ultimately, the woman can choose what makes the most sense for her at that specific time in her life, and as providers we must support and uphold that decision.
References
- Hills SD, Marchbanks PA, Tylor LR, Peterson HB. Poststerilization regret: findings from the United States Collaborative Review of Sterilization. Obstet Gynecol. 1999;93(6):889-895.
- Curtis KM, Mohllajee AP, Peterson HB. Regret following female sterilization at a young age: a systematic review. Contraception. 2006;73(2):205-210.
- Schmidt JE, Hillis SD, Marchbanks PA, Jeng G, Peterson HB. Requesting information about and obtaining reversal after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization. Fertil Steril. 2000;74(5):892-898.
- Steiner MJ, Trussell J, Mehta N, Condon S, Subramaniam S, Bourne D. Communicating contraceptive effectiveness: a randomized controlled trial to inform a World Health Organization family planning handbook. Am J Obstet Gynecol. 2006;195(1):85-91.
- Steiner MJ, Trussell J, Johnson S. Communicating contraceptive effectiveness: an updated counseling chart. Am J Obstet Gynecol. 2007;197(1):118.