Does total removal of the tubes affect ovarian reserve?
Ganer Herman H, Gluck O, Keidar R, et al. Ovarian reserve following cesarean section with salpingectomy vs tubal ligation: a randomized trial. Am J Obstet Gynecol. 2017;doi: 10.1016/j.ajog.2017.04.028.
As acceptability of total salpingectomy for permanent contraception increases, one concern is that complete removal may alter blood supply to the ovary, resulting in decreased ovarian reserve and, subsequently, earlier menopause. Several studies have addressed the potential effect of salpingectomy on ovarian function when performed at the time of hysterectomy, most of which have noted no difference in anti-Müllerian hormone (AMH) levels and sonographic parameters following surgery.19 However, very little has been published to assess this same question when the salpingectomy is performed for the purpose of permanent contraception.
Ganer Herman and colleagues aimed to assess short-term ovarian reserve by measuring AMH levels preoperatively and 6 to 8 weeks postoperatively in patients undergoing partial or total salpingectomy at the time of elective cesarean delivery.
Related article:
Salpingectomy after vaginal hysterectomy: Technique, tips, and pearls
Details of the study
The study included women aged 18 to 45 who presented for elective cesarean delivery and who requested permanent contraception. Exclusion criteria included previous tubal surgery, emergent cesarean delivery, personal history of breast carcinoma, familial history of ovarian carcinoma, and BRCA carriage.
Women were randomly assigned at a 1:1 ratio to bilateral total salpingectomy or bilateral partial salpingectomy. A complete blood count and AMH level were drawn the night prior to surgery. Intraoperatively, after delivery and hysterotomy closure, partial salpingectomy, via the Parkland technique, or total salpingectomy, using a suture ligation technique, was performed.
Of the 46 women enrolled, follow-up was completed by 16 of 22 women (72%) in the total salpingectomy group and 18 of 24 women (75%) in the partial salpingectomy group. Patients in the total salpingectomy group were slightly older (mean age, 37 vs 34 years; P = .02), but otherwise all demographic and obstetric characteristics were comparable.
No differences were noted in preoperative and postoperative AMH levels between groups, with an average (SD) increase of 0.58 (0.98) ng/mL versus 0.39 (0.41) ng/mL in the total salpingectomy and partial salpingectomy groups, respectively (P = .45), consistent with known postpartum AMH level trends.
Other findings included an average 13-minute increase in operative time in the total salpingectomy cases, similar safety profile of the 2 methods as there were no postoperative complications during the study period, and no differences in postoperative hemoglobin levels.
WHAT THIS EVIDENCE MEANS FOR PRACTICE
This study was designed as a pilot trial to assess feasibility of enrollment, safety, and short-term ovarian reserve after salpingectomy for permanent contraception. Although the study is small and does not assess long-term effects, the findings are reassuring, especially in conjunction with other data.
A meta-analysis demonstrated no effect on ovarian reserve up to 18 months after salpingectomy based on AMH changes.19 A 5-year follow-up evaluation of 71 women undergoing total laparoscopic hysterectomy with bilateral salpingectomy also showed no effect on ovarian reserve as measured by multiple hormone levels including AMH and ultrasonographic findings.20 Thus, it is highly unlikely that a permanent contraception procedure that does not include removal of the uterus will have long-term ovarian reserve effects.
Additionally, consistent with other trials, Ganer Herman and colleagues demonstrate a slightly increased operative time and no increased complications. The surgical technique used in the study reflects the concern for postoperative bleeding from the mesosalpinx, and methods that ensure excellent hemostasis with suture ligation were used.
Conclusion
The studies reviewed in this article are some of the first to evaluate the feasibility and safety of opportunistic, or total, salpingectomy for permanent contraception since the ACOG and SGO recommendations were published. Just as our community has adopted the common practice of opportunistic salpingectomy at the time of hysterectomy, we should continue to advocate for a similar practice when discussing permanent contraception. Additionally, the Westberg study provides good evidence that educational initiatives can influence provider practices, which upholds the data published by McAlpine and colleagues in British Columbia. This information is promising and valuable.
Our universal goal as ObGyns is to provide the best reproductive health care possible based on the most recent evidence available. Continuing to advocate for opportunistic salpingectomy for permanent contraception purposes meets this goal and potentially provides significant noncontraceptive benefits.
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