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Guidelines on Opportunistic Salpingectomy and IVF
LETTER TO THE EDITOR
Guidelines on Opportunistic Salpingectomy and IVF To the Editor I would like to add something to the Clinical Practice Guideline on Opportunistic Salpingectomy. Unintended pregnancies often seem to cause more misery than does infertility, certainly on a population level. Nonetheless, many couples are subfertile—frequently age related—and undergo IVF. Women who become pregnant after IVF have high rates of CS.1 Because it feels counterintuitive for doctors and patients, the couples involved are not often counselled antenatally—weeks before term—about the option of bilateral total salpingectomy (BTS) in the event of CS. However, it seems unethical not to inform pregnant patients about facts relevant to them.2 BTS is much easier to perform during CS than laparoscopically later, also because there may be adhesions after CS. Women who become pregnant after IVF are ideal candidates for BTS counselling, and this group arguably includes not only women who might consider their family complete after a CS. If another pregnancy is desired after a postIVF delivery, then this pregnancy should be planned to start reasonably soon, especially if the woman is somewhat older, often again through IVF. There may still be some blastocysts or oocytes in the freezer anyway. If the woman was not sterilized, then attempting natural conception first may “waste” many months while the ovaries age further and the gametes of both partners are more likely to become damaged in vivo. In contrast, without BTS there is the small risk that the woman will conceive naturally soon after CS, possibly resulting in a suboptimal scar. The increased risk of ectopic pregnancy attached to IVF treatment will virtually disappear if BTS was performed during a previous CS. A reduced
future risk of ovarian cancer is a welcome bonus. Moreover, BTS is more or less guaranteed to prevent method failure. This is important because couples who are very grateful that IVF or ICSI made it possible to have the family they so eagerly wanted tend to be particularly upset when facing an unintended, completely unexpected pregnancy (contraception is often thought to be unnecessary or practised haphazardly for perhaps even 15 years) when the woman is 37 to 49 years old. Such women are regularly seen in abortion clinics, but there is seldom feedback to the IVF doctors and to those who saw these women antenatally and performed the CS procedures. Consequently, these doctors do not change their counselling practices.3 For more details, see my recent article.4 Douwe A. Verkuyl, FRCOG, PhD CASA Clinics, Leiden, Leinweberlaan 16, Driebergen, 3971KZ, The Netherland
REFERENCES 1. Pandey S, Shetty A, Hamilton M, et al. Obstetric and perinatal outcomes in singleton pregnancies resulting from IVF/ICSI: a systematic review and meta-analysis. Hum Reprod Update 2012;18:485–503. 2. Chan SS, Tulloch E, Cooper ES, et al. Montgomery and informed consent: where are we now? BMJ 2017;357:j2224. 3. Chor J, Tusken M, Lyman P, et al. Factors shaping women’s pre-abortion communication with their regular gynecologic care providers. Womens Health Issues 2016;26:437–41. 4. Verkuyl DA. Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it. Contracept Reprod Med 2016;1:23. Available at: https://doi.org/10.1186/s40834-016-0034-1.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.07.012 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.
■■ JOGC ■■ 2017 • 1
Guidelines on Opportunistic Salpingectomy and IVF To the Editor I would like to add something to the Clinical Practice Guideline on Opportunistic Salpingectomy. Unintended pregnancies often seem to cause more misery than does infertility, certainly on a population level. Nonetheless, many couples are subfertile—frequently age related—and undergo IVF. Women who become pregnant after IVF have high rates of CS.1 Because it feels counterintuitive for doctors and patients, the couples involved are not often counselled antenatally—weeks before term—about the option of bilateral total salpingectomy (BTS) in the event of CS. However, it seems unethical not to inform pregnant patients about facts relevant to them.2 BTS is much easier to perform during CS than laparoscopically later, also because there may be adhesions after CS. Women who become pregnant after IVF are ideal candidates for BTS counselling, and this group arguably includes not only women who might consider their family complete after a CS. If another pregnancy is desired after a postIVF delivery, then this pregnancy should be planned to start reasonably soon, especially if the woman is somewhat older, often again through IVF. There may still be some blastocysts or oocytes in the freezer anyway. If the woman was not sterilized, then attempting natural conception first may “waste” many months while the ovaries age further and the gametes of both partners are more likely to become damaged in vivo. In contrast, without BTS there is the small risk that the woman will conceive naturally soon after CS, possibly resulting in a suboptimal scar. The increased risk of ectopic pregnancy attached to IVF treatment will virtually disappear if BTS was performed during a previous CS. A reduced
future risk of ovarian cancer is a welcome bonus. Moreover, BTS is more or less guaranteed to prevent method failure. This is important because couples who are very grateful that IVF or ICSI made it possible to have the family they so eagerly wanted tend to be particularly upset when facing an unintended, completely unexpected pregnancy (contraception is often thought to be unnecessary or practised haphazardly for perhaps even 15 years) when the woman is 37 to 49 years old. Such women are regularly seen in abortion clinics, but there is seldom feedback to the IVF doctors and to those who saw these women antenatally and performed the CS procedures. Consequently, these doctors do not change their counselling practices.3 For more details, see my recent article.4 Douwe A. Verkuyl, FRCOG, PhD CASA Clinics, Leiden, Leinweberlaan 16, Driebergen, 3971KZ, The Netherland
REFERENCES 1. Pandey S, Shetty A, Hamilton M, et al. Obstetric and perinatal outcomes in singleton pregnancies resulting from IVF/ICSI: a systematic review and meta-analysis. Hum Reprod Update 2012;18:485–503. 2. Chan SS, Tulloch E, Cooper ES, et al. Montgomery and informed consent: where are we now? BMJ 2017;357:j2224. 3. Chor J, Tusken M, Lyman P, et al. Factors shaping women’s pre-abortion communication with their regular gynecologic care providers. Womens Health Issues 2016;26:437–41. 4. Verkuyl DA. Recent developments have made female permanent contraception an increasingly attractive option, and pregnant women in particular ought to be counselled about it. Contracept Reprod Med 2016;1:23. Available at: https://doi.org/10.1186/s40834-016-0034-1.
J Obstet Gynaecol Can 2017;■■(■■):■■–■■ https://doi.org/10.1016/j.jogc.2017.07.012 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.
■■ JOGC ■■ 2017 • 1