Salpingectomy as a Primary Sterilization Procedure?

Larry Hand

August 08, 2014

Salpingectomy should be the primary female sterilization procedure because it is permanent and may prevent some types of ovarian cancer that actually begin in the Fallopian tube, according to a commentary published online August 5 in Obstetrics & Gynecology.

Recent research findings that ovarian cancer may frequently originate in the Fallopian tube, along with advances in technology making salpingectomy no greater risk than tubal occlusion, warrant consideration of this practice-changing move, Mitchell D. Creinin, MD, chair of obstetrics and gynecology at the University of California, Davis, and Nikki Zite, MD, MPH, associate professor of obstetrics and gynecology at the University of Tennessee, Knoxville, write in their commentary.

Whether performed remote from pregnancy or at or near the time of delivery, female sterilization procedures are "highly effective," they write. Tubal interruption has long been the primary method of sterilization.

However, Dr. Creinin and Dr. Zite write, "If we had included the patient in the discussion, perhaps the higher efficacy of salpingectomy would have been what women desired all along."

New evidence that serous adenocarcinoma, the most common ovarian cancer, may originate in the Fallopian tube has caused an increase in the performance of salpingectomy as a sterilization method, and studies have shown that surgical risks are about equal between salpingectomy and tubal interruption, the authors write.

Yet "the question should not be focused only on ovarian cancer prevention; rather, the more important question should be why we are not offering women a chance for near 100% efficacy by removing the Fallopian tube completely for sterilization," Dr. Creinin and Dr. Zite write.

Beginning to Shift

Recent research indicates that clinicians are more often considering salpingectomy for sterilization for women who are at high risk for cancer because of BRCA mutations, the authors write, but a bigger question is whether gynecologists would consider changing clinical norms to use salpingectomy for women without BRCA mutations.

Some clinicians may still be concerned about issues such as the need for a larger incision for salpingectomy after vaginal delivery, increased cost resulting from the need for an additional 10 minutes of operating time, and the risk for regret in some women, they write, but evidence is on the side of salpingectomy.

They cite results from a large study in British Columbia, Canada, suggesting that after a regional initiative to educate general gynecologists, clinicians started using bilateral salpingectomy more often with hysterectomy than tubal ligation, and morbidity was no different.

They conclude, "Our technology has advanced such that salpingectomy may have no greater risk than tubal occlusion. The information is coming at us quickly; most importantly, let's not forget to truly include women in the conversation by offering salpingectomy as an option simply because it is the most effective method. Knowing the safety and efficacy of salpingectomy today, we wonder whether women would have been choosing to remove the Fallopian tubes all along."

Ongoing Research

"Our study shows that for these major issues, there's no increased risk for the [salpingectomy] procedure, but it will take at least another 10 to 15 years to look at the effectiveness," Jessica N. McAlpine, MD, associate professor of gynecologic oncology at the University of British Columbia, Vancouver, Canada, and lead author for the British Columbia study mentioned earlier, told Medscape Medical News.

"If you're looking at whether it will impact and decrease ovarian cancer, that's going to take time," she continued. "What's key in all of this is that for the general population, there's no adequate screening, there's no major change in treatment outcomes for this disease for the last 3 decades. This intervention, we think, will make a difference. It seems to be safe, and we're looking at it as our best option."

In terms of effectiveness, smaller studies show decreases in ovarian cancer, Dr. McAlpine said, "but they're very small."

Asked whether there is any reason not to remove the Fallopian tube, she said, "We don't think there is. Historically, it has been easier to place a clamp adjacent to the uterus and leave the tube and ovary together. I think it was just surgical practice."

Some people, she added, are concerned about possible subtle hormonal changes. "But if you do it correctly...we don't think that's the case." Studies are under way.

Dr. McAlpine summed it up: "I think it's fantastic that more people are looking to do [salpingectomy] because it may save the next generation of women from ever developing this disease, but I wouldn't overstate what we have done so far."

Need Data

"I get what they're arguing. It's just that it's important to recognize that there hasn't been any substantial prospective data for this. It's all based on inference and retrospective analysis," William D. Foulkes, PhD, professor in the Program in Cancer Genetics at McGill University, Montreal, Quebec, and cancer genetics section editor for Current Oncology, told Medscape Medical News, He wrote a commentary on this topic last year.

"What we don't know is what proportion of ovarian cancer in the general population arises from the Fallopian tube. That's a critical question," he continued. Another number needed is what proportion of sporadic, nongenetic cancer arises in the Fallopian tube, he added.

"If you're thinking that this is going to significantly affect ovarian cancer incidence, then it has to be that the vast majority of ovarian cancer [cases] arise in the Fallopian tube," he said.

A potential parallel approach would be to offer genetic testing to as many people as possible, he suggested. "Clearly if you have a higher risk of ovarian cancer through your genes, that risk is way out of proportion to any risk in the general population, so finding women at high risk can save a lot of lives directly. The number of Fallopian tubes removed to save a life is probably much less if you actually know that a person is high-risk."

More research is needed also regarding potential risks, he said. "It's obviously more complicated than putting a clip on the Fallopian tube, and...there is a reality to the fact that some women may regret the decision if they are younger. Obviously if you remove the entire tube, that's it."

He concluded, "I'm not opposed to the idea of this at all. I just think you have to careful as to what is the benefit. I'm just questioning the size of the effect. I can imagine that many women, if they needed it, might think differently about it."

The authors, Dr. McAlpine, and Dr. Foulkes have disclosed no relevant financial relationships.

Obstet Gynecol. Published online August 5, 2014. Abstract

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