By Rebecca H. Allen, MD, MPH
Associate Professor, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Women and Infants Hospital, Providence, RI
Dr. Allen reports she is a Nexplanon trainer for Merck.
In this retrospective cohort study, almost 20% of women who desired bilateral complete salpingectomy for permanent contraception at the time of cesarean delivery could not undergo the procedure because of adhesions or engorged vasculature.
Lehn K, Gu L, Creinin MD, Chen MJ. Successful completion of total and partial salpingectomy at the time of cesarean delivery. Contraception 2018;98:232-236.
Lehn et al conducted a retrospective study of all 122 women who underwent permanent contraception procedures during cesarean delivery at the University of California Davis Medical Center between November 2015 and April 2017. This time period was the first 18 months after an education program was presented to increase physician awareness of complete salpingectomy as an option for permanent contraception after cesarean delivery. The authors collected data from the operative report, as well as demographic data, obstetric data, body mass index (BMI), medical comorbidities, previous abdominal surgeries, and smoking status. Surgical complications, blood transfusion, prolonged hospitalization (more than four days), hospital readmission, and reoperation also were evaluated. Procedure type could include complete salpingectomy, partial salpingectomy, or a mixed procedure (complete on one side and partial on the other).
The proportion of planned complete salpingectomy procedures increased from 50% in the first three months of the study to 94.1% in the last three months (P < 0.01). Among the 32 (26.2%) women who desired partial salpingectomy, all underwent successful procedures. For the 90 (73.8%) women who desired complete salpingectomy, 17 (18.9%) could not undergo the procedure. Surgeons performed a mixed procedure in nine women because of adhesive disease (n = 4), proximity to large vessels in the mesosalpinx (n = 3), or both (n = 2). They performed bilateral partial salpingectomy in seven women because of adhesive disease (n = 4), engorged vasculature (n = 1), or unspecified reasons (n = 2). One woman was not able to undergo any procedure because of adhesions. A history of three or more cesarean deliveries was associated with failure to perform bilateral complete salpingectomy compared to women with fewer cesarean deliveries (P = 0.04). There was no statistically significant difference between the two groups in operative time, estimated blood loss, need for blood transfusion, or hospital readmission.
COMMENTARY
In a U.S. study conducted between 2008 and 2013, Moniz et al estimated postpartum permanent contraception rates to be 683 to 711 per 10,000 deliveries.1 The procedure was more common in women 35 years of age and older and during cesarean compared to vaginal delivery. Traditionally, surgeons performed a partial salpingectomy technique for postpartum procedures. This technique removes a mid-isthmic segment of fallopian tube bilaterally. Complete bilateral salpingectomy in the immediate postpartum period for permanent contraception also has been described, as interest in salpingectomy increases because of its potential to decrease the risk of ovarian cancer.2,3 Bilateral salpingectomy for permanent contraception is safe and presumably more effective than partial salpingectomy, with a lower risk for ectopic pregnancy.4
Complete salpingectomy at the time of cesarean delivery has been described in several studies.5-8 Some surgeons elect to use an electrothermal bipolar tissue-sealing instrument and others opt for traditional suture ligation. In a randomized, controlled noninferiority trial, Garcia et al compared complete and partial salpingectomy using the electrothermal bipolar tissue-sealing device at the time of cesarean delivery in 37 women.7 Bilateral complete salpingectomy was successful in 19 of 20 women. One procedure was converted to partial salpingectomy because of adhesions. Estimated blood loss was not different between the groups. There was a a mean procedure time of 5.6 minutes in the complete salpingectomy group and 6.1 minutes in the partial salpingectomy group. In another small randomized trial, Subramaniam et al compared complete salpingectomy to partial salpingectomy in 80 women at the time of cesarean delivery, this time using suture ligation rather than the device.8 The procedure was performed successfully in 27 of 40 (68%) women randomized to complete salpingectomy and 38 of 40 (95%) women in the partial salpingectomy group. Total operative time using the suture ligation technique was 15 minutes longer for the complete salpingectomy group compared to partial salpingectomy. There was no difference between the groups in terms of estimated blood loss or complications. Women with higher BMIs and a longer time from skin incision to tubal operation start had an increased risk of a failed procedure. The authors did not report details as to why complete salpingectomy could not be performed.
Lehn et al reported that 81% of women who desired complete salpingectomy had successful procedures compared to 95% in the first randomized, controlled trial and 68% in the second randomized, controlled trial described earlier. Therefore, there is a wide range of success, which likely reflects the small sample sizes in these studies. Nevertheless, the Lehn et al study added reasons why complete salpingectomy was unsuccessful in some women, mainly because of adhesions and concerns of engorged postpartum vasculature near the fallopian tubes. Studies also reflect that the electrothermal bipolar tissue-sealing device offers a faster procedure but presumably at a higher financial cost to the hospital compared to suture ligation. Women should be counseled up front that there is a possibility that surgeons may not be able to perform complete salpingectomy and that partial salpingectomy can be offered as a backup. Of course, in some women, severe adhesions may not allow access to the fallopian tubes at all, and an alternative contraception plan should be offered. This will be true especially among women with a history of multiple cesarean deliveries. As opportunistic salpingectomy for permanent contraception becomes a more popular and accepted option for patients, surgeons will gain more experience. The data show that the procedure is safe and adds minimal operative time, but that some women may not be appropriate candidates.
REFERENCES
- Moniz MH, Chang T, Heisler M, et al. Inpatient postpartum long-acting reversible contraception and sterilization in the United States, 2008-2013. Obstet Gynecol 2017;129:1078-1085.
- American College of Obstetricians and Gynecologists. Committee opinion no. 620: Salpingectomy for ovarian cancer prevention. Obstet Gynecol 2015;125:279-281.
- Powell CB, Alabaster A, Simmons S, et al. Salpingectomy for sterilization: Change in practice in a large integrated health care system, 2011-2016. Obstet Gynecol 2017;130:961-967.
- Creinin MD, Zite N. Female tubal sterilization: The time has come to routinely consider removal. Obstet Gynecol 2014;124:596-599.
- 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;295:1185-1189.
- Duncan JR, Schenone MH, Mari G. Technique for bilateral salpingectomy at the time of cesarean delivery: A case series. Contraception 2017;95:509-511.
- Garcia C, Moskowitz OM, Chisholm CA, et al. Salpingectomy compared with tubal ligation at cesarean delivery: A randomized controlled trial. Obstet Gynecol 2018;132:29-34.
- Subramaniam A, Blanchard CT, Erickson BK, et al. Feasibility of complete salpingectomy compared with standard postpartum tubal ligation at cesarean delivery: A randomized controlled trial. Obstet Gynecol 2018;132:20-27.
