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Guidelines About Opportunistic Salpingectomy, IVF, and the Practical Side – In Response
LETTER TO THE EDITOR
Guidelines About Opportunistic Salpingectomy, IVF, and the Practical Side – In Response To the Editor: The authors of the Clinical Practice Guidelines concerning Opportunistic Salpingectomy1 would like to thank Dr. Verkuyl for the recent letter that brings up an important issue with IVF and salpingectomy. Many women who undergo IVF and have an increased likelihood of a Caesarean delivery are frequently not counselled about the option of a bilateral total salpingectomy at the time of CS. Offering this may be an excellent option, as we know that women with hydrosalpinx or other tubal issues have an increased chance of a viable pregnancy with IVF after tubal occlusion or removal surgery.2 For women wishing to pursue a second pregnancy, removing the fallopian tubes at the time of CS could increase the odds of a second IVF procedure working. The chance of spontaneous pregnancy after IVF is about 17% with a medium of six years for the birth of the next child; however a majority of these pregnancies are in couples <35 years of age and have unexplained infertility,3 so, as Dr. Verkuyl states, “attempt for natural conception may ‘waste’ many months” in women over the age of 35. There are many studies evaluating ovarian function after salpingectomy with amount of gonadotropin administered, peak E2 level, number of oocytes retrieved, and resulting pregnancies that appear to show no negative effect of subsequent fertility.4 Given the increased blood flow surrounding the fallopian tubes during pregnancy, it could be argued that a salpingectomy is harder to do at the time of CS versus performing one laproscopically later. However, since the publication of the guideline, there are more studies showing the safety of salpingectomy at the time of CS,5 and it avoids a second surgery and the complications that can come from one. Moreover, it is a missed opportunity to discuss this procedure with women who are completing their child-bearing and have no desire for further pregnancies. As this procedure also may offer the additional benefit of reducing the risk of a high-grade serous cancer of gynaecologic origin, it’s an opportunity that should be discussed. We also appreciate the addition of the practical surgical points of Opportunistic Salpingectomy as written by the
Ottawa MIS Gynecology Group. Our guideline leaves the judgement of personal surgical skills up to the reader to determine if one could perform a salpingectomy without any additional training. There are a growing number of resources being published on the technique of salpingectomy during various procedures. A recently published article on salpingectomy at CS also includes an online video demonstrating their technique, and even in these experienced hands, a complete bilateral salpingectomy was not performed on two of their 23 patients due to adhesions found at the time of the surgery.6 To bring this skill set to all areas across our country, it may be necessary for practitioners to seek in-service training at supportive sites with their colleagues. As for additional cost to the health care system, two other papers have also run cost-effectiveness models and show that addition of salpingectomy to laparoscopic hysterectomy/sterilization and vaginal hysterectomy is cost-saving with the potential subsequent decrease in cancer and benign adnexal surgery.7,8 The practical “Tips” that are offered in the letter are a useful addition to our guideline. Shannon Salvador, MD;1 Stephanie Scott, MD;2 Julie Ann Francis, MD;3 Anita Agrawal, MD,4 Christopher Giede, MD4 1 Jewish General Hospital, Montreal, QC 2
Dalhousie University, Halifax, NS
3
Queen’s University, Kingston, ON
4
University of Saskatchewan, Saskatoon, SK
REFERENCES 1. Salvador S, Scott S, Francis JA, et al. No. 344-opportunistic salpingectomy and other methods of risk reduction for ovarian/fallopian tube/peritoneal cancer in the general population. J Obstet Gynaecol Can 2017;39:480– 93. 2. Tsiami A, Chaimani A, Mavridis D, et al. Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer: a network metaanalysis. Ultrasound Obstet Gynecol 2016;48:434–45. 3. Troude P, Bailly E, Guibert J, et al. Spontaneous pregnancies among couples previously treated by in vitro fertilization. Fertil Steril 2012;98:63– 8. 4. Kotlyar A, Gingold J, Shue S, et al. The effect of salpingectomy on ovarian function. J Minim Invasive Gynecol 2017;24:563–78. 5. 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. e-pub ahead of print.
■■ JOGC ■■ 2017 • 1
LETTER TO THE EDITOR
6. Duncan JR, Schenone MH, Mari G. Technique for bilateral salpingectomy at the time of Cesarean delivery: a case series. Contraception 2017;95:509–11. 7. Dilley SE, Havrilesky LJ, Bakkum-Gamez J, et al. Cost-effectiveness of opportunistic salpingectomy for ovarian cancer prevention. Gynecol Oncol 2017;146:373–9. 8. Cadish LA, Shepherd JP, Barber EL, et al. Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis. Am J
2 • ■■ JOGC ■■ 2017
Obstet Gynecol 2017;doi:10.1016/j.ajog.2017.06.007. e-pub ahead of print.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.08.001 Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
Guidelines About Opportunistic Salpingectomy, IVF, and the Practical Side – In Response To the Editor: The authors of the Clinical Practice Guidelines concerning Opportunistic Salpingectomy1 would like to thank Dr. Verkuyl for the recent letter that brings up an important issue with IVF and salpingectomy. Many women who undergo IVF and have an increased likelihood of a Caesarean delivery are frequently not counselled about the option of a bilateral total salpingectomy at the time of CS. Offering this may be an excellent option, as we know that women with hydrosalpinx or other tubal issues have an increased chance of a viable pregnancy with IVF after tubal occlusion or removal surgery.2 For women wishing to pursue a second pregnancy, removing the fallopian tubes at the time of CS could increase the odds of a second IVF procedure working. The chance of spontaneous pregnancy after IVF is about 17% with a medium of six years for the birth of the next child; however a majority of these pregnancies are in couples <35 years of age and have unexplained infertility,3 so, as Dr. Verkuyl states, “attempt for natural conception may ‘waste’ many months” in women over the age of 35. There are many studies evaluating ovarian function after salpingectomy with amount of gonadotropin administered, peak E2 level, number of oocytes retrieved, and resulting pregnancies that appear to show no negative effect of subsequent fertility.4 Given the increased blood flow surrounding the fallopian tubes during pregnancy, it could be argued that a salpingectomy is harder to do at the time of CS versus performing one laproscopically later. However, since the publication of the guideline, there are more studies showing the safety of salpingectomy at the time of CS,5 and it avoids a second surgery and the complications that can come from one. Moreover, it is a missed opportunity to discuss this procedure with women who are completing their child-bearing and have no desire for further pregnancies. As this procedure also may offer the additional benefit of reducing the risk of a high-grade serous cancer of gynaecologic origin, it’s an opportunity that should be discussed. We also appreciate the addition of the practical surgical points of Opportunistic Salpingectomy as written by the
Ottawa MIS Gynecology Group. Our guideline leaves the judgement of personal surgical skills up to the reader to determine if one could perform a salpingectomy without any additional training. There are a growing number of resources being published on the technique of salpingectomy during various procedures. A recently published article on salpingectomy at CS also includes an online video demonstrating their technique, and even in these experienced hands, a complete bilateral salpingectomy was not performed on two of their 23 patients due to adhesions found at the time of the surgery.6 To bring this skill set to all areas across our country, it may be necessary for practitioners to seek in-service training at supportive sites with their colleagues. As for additional cost to the health care system, two other papers have also run cost-effectiveness models and show that addition of salpingectomy to laparoscopic hysterectomy/sterilization and vaginal hysterectomy is cost-saving with the potential subsequent decrease in cancer and benign adnexal surgery.7,8 The practical “Tips” that are offered in the letter are a useful addition to our guideline. Shannon Salvador, MD;1 Stephanie Scott, MD;2 Julie Ann Francis, MD;3 Anita Agrawal, MD,4 Christopher Giede, MD4 1 Jewish General Hospital, Montreal, QC 2
Dalhousie University, Halifax, NS
3
Queen’s University, Kingston, ON
4
University of Saskatchewan, Saskatoon, SK
REFERENCES 1. Salvador S, Scott S, Francis JA, et al. No. 344-opportunistic salpingectomy and other methods of risk reduction for ovarian/fallopian tube/peritoneal cancer in the general population. J Obstet Gynaecol Can 2017;39:480– 93. 2. Tsiami A, Chaimani A, Mavridis D, et al. Surgical treatment for hydrosalpinx prior to in-vitro fertilization embryo transfer: a network metaanalysis. Ultrasound Obstet Gynecol 2016;48:434–45. 3. Troude P, Bailly E, Guibert J, et al. Spontaneous pregnancies among couples previously treated by in vitro fertilization. Fertil Steril 2012;98:63– 8. 4. Kotlyar A, Gingold J, Shue S, et al. The effect of salpingectomy on ovarian function. J Minim Invasive Gynecol 2017;24:563–78. 5. 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. e-pub ahead of print.
■■ JOGC ■■ 2017 • 1
LETTER TO THE EDITOR
6. Duncan JR, Schenone MH, Mari G. Technique for bilateral salpingectomy at the time of Cesarean delivery: a case series. Contraception 2017;95:509–11. 7. Dilley SE, Havrilesky LJ, Bakkum-Gamez J, et al. Cost-effectiveness of opportunistic salpingectomy for ovarian cancer prevention. Gynecol Oncol 2017;146:373–9. 8. Cadish LA, Shepherd JP, Barber EL, et al. Risks and benefits of opportunistic salpingectomy during vaginal hysterectomy: a decision analysis. Am J
2 • ■■ JOGC ■■ 2017
Obstet Gynecol 2017;doi:10.1016/j.ajog.2017.06.007. e-pub ahead of print.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.08.001 Copyright © 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.