Durable contraception in the female domestic cat using viral-vectored delivery of a feline anti-Müllerian hormone transgene.

Eighty percent of the estimated 600 million domestic cats in the world are free-roaming. These cats typically experience suboptimal welfare and inflict high levels of predation on wildlife. Additionally, euthanasia of healthy animals in overpopulated shelters raises ethical considerations. While surgical sterilization is the mainstay of pet population control, there is a need for efficient, safe, and cost-effective permanent contraception alternatives. Herein, we report evidence that a single intramuscular treatment with an adeno-associated viral vector delivering an anti-Müllerian hormone transgene produces long-term contraception in the domestic cat. Treated females are followed for over two years, during which transgene expression, anti-transgene antibodies, and reproductive hormones are monitored. Mating behavior and reproductive success are measured during two mating studies. Here we show that ectopic expression of anti-Müllerian hormone does not impair sex steroids nor estrous cycling, but prevents breeding-induced ovulation, resulting in safe and durable contraception in the female domestic cat.

Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study.

OBJECTIVE: To compare real-world effectiveness of hysteroscopic to laparoscopic sterilization. DESIGN: Retrospective cohort of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical variables to examine the poststerilization pregnancy rates. SETTING: Clinics, hospitals. PATIENT(S): Women aged 18-50 years with Medicaid claims between January 1, 2008, and August 31, 2014. INTERVENTION(S): Hysteroscopic or laparoscopic sterilization procedure. MAIN OUTCOME MEASURE(S): Poststerilization pregnancy measured by pregnancy-related claims. RESULT(S): Among women with hysteroscopic (n = 5,906) or laparoscopic (n = 23,965) sterilization, poststerilization pregnancy claims were identified for 4.74% of women after hysteroscopic sterilization and 5.57% after laparoscopic sterilization. The pregnancy rates decreased over time after either procedure. Twelve months after the procedure, the crude incidence of pregnancy claims was higher for hysteroscopic sterilization than for laparoscopic sterilization (3.26 vs. 2.61 per 100 woman-years), but the propensity-weighted adjusted incidence rate ratio was 1.06 (95% confidence interval [CI], 0.85-1.26). Between 13 and 24 months after the procedure, there were fewer pregnancies for women after hysteroscopic sterilizations than for those after laparoscopic sterilizations (adjusted incidence rate ratio, 0.63 [95% CI, 0.45-0.88]), with no statistically significant differences in later years. The cumulative pregnancy rates 5 years after sterilization were lower with hysteroscopic sterilization than with laparoscopic sterilization (6.26 vs. 7.22 per 100 woman-years; propensity-weighted, adjusted risk ratio, 0.76 [95% CI, 0.62-0.90]). The poststerilization pregnancy rates varied by age and race/ethnicity. CONCLUSION(S): The pregnancy rates after female sterilization are higher than expected, whether performed hysteroscopically or laparoscopically. These findings are reassuring that the effectiveness of hysteroscopic sterilization was not inferior to laparoscopic sterilization. CLINICAL TRIAL REGISTRATION NUMBER: NCT03438682.

Patient-Centered Safety Outcomes After Hysteroscopic Compared With Laparoscopic Sterilization.

OBJECTIVE: To evaluate the real-world safety of hysteroscopic compared with laparoscopic surgical sterilization. METHODS: We conducted a retrospective cohort study of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014, among women aged 18-50 years. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical characteristics that may affect outcomes of interest to patients and physicians. We assessed the following outcomes: procedural complications, additional surgical procedures (eg, hysterectomy), repeat sterilization procedures, pelvic pain, pelvic inflammatory disease (PID), abdominal pain, nonabdominal pain, and abnormal uterine bleeding. RESULTS: We identified 5,906 women who had undergone hysteroscopic and 23,965 who had undergone laparoscopic sterilization. After adjusting for sociodemographic and health history, women who had hysteroscopic sterilization were less likely to have claims for procedural complications (eg, transfusion, P<.001) on the day of surgical sterilization and additional surgical procedures (eg, hysterectomy, P=.002 at day 2-3 months postprocedure) than laparoscopic sterilization. Claims for a repeat attempt at sterilization were more common after hysteroscopic sterilization within 1 year (adjusted incident rate ratio 3.48, 95% CI 2.69-4.27) and within 5 years (adjusted incident rate ratio 2.32, 95% CI 1.84-2.79) than laparoscopic sterilization. Claims for pelvic pain (adjusted incident rate ratio 0.77, 95% CI 0.65-0.92 at 2 years), abdominal pain (adjusted incident rate ratio 0.80, 95% CI 0.68-0.93 at 7-12 months), and PID (adjusted incident rate ratio 0.55, 95% CI 0.33-0.93 at 2 years) were less common after hysteroscopic than laparoscopic sterilization. Although abnormal uterine bleeding claims were more common after hysteroscopic than laparoscopic sterilization up to 12 months postprocedure (adjusted incident rate ratio 1.37, 95% CI 1.06-1.77 at 7-12 months), there were no significant differences between methods 1 year after the procedure. CONCLUSION: Compared with laparoscopic sterilization, hysteroscopic sterilization was followed by more claims for repeat sterilization procedures and abnormal uterine bleeding, but fewer procedural complications and fewer claims for pelvic or abdominal pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03438682.

Symptomatology and Serum Nuclear Magnetic Resonance Metabolomics; Do They Predict Endometriosis in Fertile Women Undergoing Laparoscopic Sterilisation? A Prospective Cross-sectional Study.

Endometriosis is a common, chronic inflammatory condition, thought to have a higher incidence in symptomatic women, yet, commonly associated symptoms do not always correlate with the presence or severity of disease and diagnosis requires surgery. We prospectively collected data and assessed symptomology and NMR spectroscopy-based metabolomics of 102 women undergoing laparoscopic sterilisation at a tertiary referral centre in a cross-sectional study. Twelve women were incidentally diagnosed with endometriosis (11.7%). According to the pre-operative questionnaire, presence and absence of many symptoms usually attributed to endometriosis were declared at similar frequencies in women with or without endometriosis. Women with endometriosis reported apparently more persistent heavy periods (50% vs 18.9%), prolonged periods (25% versus 7.8%) and problems conceiving (27.3% versus 9%) than those without endometriosis. NMR could not discern any distinguishable differences in the serum metabolome between those with and without endometriosis. Our paper highlights the complex symptomology experienced by women, regardless of a surgical diagnosis of endometriosis. Previous literature and the current study failed to identify clear, distinguishable symptoms or biomarkers pertinent to surgically confirmed endometriosis in the general population. Therefore, development of effective, non-invasive tests for identifying this heterogenous benign condition, endometriosis, is likely to be challenging.

What happened to quinacrine non-surgical female sterilization?

Quinacrine sterilization (QS) is a nonsurgical female method used by more than 175,000 women in over 50 countries. With FDA approval, QS is expected to be used by hundreds of millions of women. The negative international health consequences of the results of a 2-year rat study in 2010 by Cancel et al. in Regulatory Toxicology and Pharmacology (RTP) (56:156-165) are incalculable. S1C(R2) was ignored in this study, including the fundamental concept of maximum tolerated dose (MTD), which resulted in the use of massive doses (up to 35 times the MTD) which killed many of the rats and destroyed the uterus of survivors. The design of this rat study was built on the false assertion that this study mimics what happens in women. Cancel et al. (2010), concludes it "seems most likely" that genotoxicity was a major factor in the carcinogenicity observed, prompting the FDA to halt further research of QS. In RTP, McConnell et al. (2010), and Haseman et al. (2015), using the authors' data, definitively determined the carcinogenicity to be secondary to necrosis and chronic inflammation. Decisions made in the design, conduct, analysis, interpretation and reporting in this study lack scientific foundation. This paper explores these decisions.

Salpingectomy vs tubal ligation for sterilization: a systematic review and meta-analysis.

OBJECTIVE: After strong evidence and major organizations recommending salpingectomy over tubal ligation, we sought to perform a systematic review and meta-analysis comparing the intraoperative attributes and complication rates associated with these 2 procedures. DATA SOURCES: We searched PubMed, the Cochrane Library, Embase, and clinical trials registries without time or language restrictions. The search was conducted in February 2020. Database searches revealed 74 potential studies, of which 11 were examined at the full-text level. Of these, 6 studies were included in the qualitative analysis and 5 studies were included in the meta-analysis. STUDY ELIGIBILITY CRITERIA: We included randomized controlled trials comparing salpingectomy with tubal ligation in women seeking sterilization. We included studies that also had at least 1 outcome listed in the population/patient problem, intervention, comparison, outcome, and time. Articles were excluded if they did not meet the inclusion criteria or if data were not reported and the authors did not respond to inquiries. STUDY APPRAISAL AND SYNTHESIS METHODS: Abstracts and full-text articles were assessed by 2 authors independently using the blinded coding assignment function or EPPI-Reviewer 4. Conflicting selections were resolved by consensus. The quality of included studies was determined using the Cochrane Collaboration tool for assessing the risk of bias in randomized trials. Two authors independently assessed the risk of bias for each study; disagreements were resolved by consensus. RESULTS: There were few differences between the procedures, with no differences in most important clinical outcomes (antimüllerian hormone, blood loss, length of hospital stay, pre- or postoperative complications, or wound infections). A single study reported a reduced rate of pregnancies with salpingectomy (risk ratio, 0.22; 95% confidence interval, 0.05-1.02), but this did not reach statistical significance (P=.05). CONCLUSION: We conclude from these data that salpingectomy is as safe and efficacious as tubal ligation for sterilization and may be preferred, where appropriate, to reduce the risk of ovarian cancer.

Enhanced recovery after surgery outcomes in minimally invasive nonhysterectomy gynecologic procedures.

BACKGROUND: Improved patient outcomes and satisfaction associated with enhanced recovery after surgery protocols have increasingly replaced traditional perioperative anesthesia care. Fast-track surgery pathways have been extensively validated in patients undergoing hysterectomies, yet the impact on fertility-sparing laparoscopic gynecologic operations, particularly those addressing chronic pain conditions, has not been examined. OBJECTIVE: The objective of the study was to determine the effects of enhanced recovery after surgery pathway implementation compared with conventional perioperative care in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures. STUDY DESIGN: We conducted a retrospective cohort study of women undergoing uterine-sparing laparoscopic gynecologic procedures for benign conditions (tubal/adnexal pathology, endometriosis, or leiomyomas) during a 24 month period before and after enhanced recovery after surgery implementation at a tertiary care center. We compared immediate perioperative outcomes and 30 day complications. The primary outcome was same-day discharge rates. Factors influencing unplanned admissions, postoperative pain, sedation, nausea, and vomiting represented secondary analyses. RESULTS: A total of 410 women (enhanced recovery after surgery, n = 196; conventional perioperative care, n = 214) met inclusion criteria. Following enhanced recovery after surgery implementation, same-day discharge rates increased by 9.4% (P = .001). Reductions in postoperative pain and nausea/vomiting represented the primary driving factor behind lower unplanned admissions. Higher preoperative antiemetic medication administration in the enhanced recovery after surgery group resulted in a 57% reduction in postanesthesia care unit antiemetics (P < .001). Total perioperative narcotic medication use was also significantly reduced by 64% (P < .001), and the enhanced recovery after surgery cohort still demonstrated significantly lower postanesthesia unit care pain scores at hours 2 and 3 (P < .001). A 19 minute shorter postanesthesia care unit stay was noted in the enhanced recovery after surgery cohort (P = .036). Increased same-day discharge did not lead to higher postoperative complications or changes in 30 day emergency department visits or readmissions in patients with enhanced recovery after surgery. CONCLUSION: Enhanced recovery after surgery implementation resulted in increased same-day discharge rates and improved perioperative outcomes without affecting 30 day morbidity in women undergoing laparoscopic minimally invasive nonhysterectomy gynecologic procedures.

A low-cost approach to salpingectomy at cesarean delivery.

There is increasing adoption of opportunistic salpingectomy for ovarian cancer prevention at the time of gynecologic surgery, which includes the postpartum period. However, there is no consensus on an ideal surgical approach for the parturient vasculature. We describe a safe, low-cost, and accessible approach for bilateral salpingectomy during cesarean delivery that we call the "Mesosalpinx Isolation Salpingectomy Technique" (MIST) that can guide institutions to standardize their postpartum salpingectomy procedures when advanced vessel-sealing devices are not available. In the MIST technique, avascular windows are created within the mesosalpinx close to the tubal vessels. The vasculature is thus fully skeletonized and isolated from the adjacent mesosalpinx before suture ligation, which ensures security of the free-tie to the individual vessels and avoids sharp injury to the mesosalpinx. Not using vessel-sealing devices also eliminates the risk of thermal injury to the adjacent ovarian tissue and vasculature and potentially achieves a cost-savings for the hospital and patient. MIST has been performed in 141 cesarean deliveries in the past 4 years. There were no noted bleeding complications during the salpingectomy procedure, blood transfusions, or instances of postoperative surgical reexploration. In our experience, a surgeon who is new to the procedure takes approximately 15 minutes to complete a bilateral salpingectomy. Those surgeons who are experienced in MIST need only 5 minutes. A video is included that demonstrates the technique.

Mechanistic insight into the role of immunocastration on eliminating skatole in boars.

The accumulation of skatole in fat tissue is one of the predominant factors, causing boar taint. The present study was aimed to understand the mechanism whereby active immunization against GnRH (immunocastration) eliminates skatole in boars. Thirty-six boars were assigned within litter into three groups (n = 12): control, surgically castrated, or immunized against GnRH at 10 wk of age (with a booster 8 wk later). Faecal and blood samples (for skatole and skatole-regulatory hormone profiles) were collected at 4-wk intervals until boars were slaughtered (26 weeks). Immunocastration reduced (P < 0.05) serum levels of androstenone, 17ß-estradiol and IGF1 especially after the booster immunization, and down-regulated (P < 0.05) mRNA expressions of both IGF1 and IGF1receptor (IGF1R) in mucosa of ileum as well as colon at slaughter. Compared to intact controls, immunocastration substantially decreased (P < 0.05) faecal skatole contents subsequent to the decrease of serum IGF1 levels, which persisted in boars after surgical castration. In parallel with the decreased formation of skatole in the intestine, levels of skatole in serum and then in fat tissue were also decreased (P < 0.05). On the other hand, deprivation of testicular steroids, especially androstenone and 17ß-estradiol accelerated skatole degradation metabolism in the liver by increasing (P < 0.05) hepatic CYP2E1, CYP2A, CYP2C49 and CYB5A expressions. Collectively, our results suggested that immunocastration decreased skatole formation in the intestine and meanwhile accelerated skatole degradation metabolism in the liver, resultantly eliminating skatole accumulation in male pigs. Decreased intestinal skatole formation by immunocastration appeared to be associated with the attenuated actions of IGF1 on the turnover of both ileal and colon mucosa.

ACOG Committee Opinion No. 774: Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention.

Opportunistic salpingectomy may offer obstetrician-gynecologists and other health care providers the opportunity to decrease the risk of ovarian cancer in their patients who are already undergoing pelvic surgery for benign disease. By performing salpingectomy when patients undergo an operation during which the fallopian tubes could be removed in addition to the primary surgical procedure (eg, hysterectomy), the risk of ovarian cancer is reduced. Although opportunistic salpingectomy offers the opportunity to significantly decrease the risk of ovarian cancer, it does not eliminate the risk of ovarian cancer entirely. Counseling women who are undergoing routine pelvic surgery about the risks and benefits of salpingectomy should include an informed consent discussion about the role of oophorectomy and bilateral salpingo-oophorectomy. Bilateral salpingo-oophorectomy that causes surgical menopause reduces the risk of ovarian cancer but may increase the risk of cardiovascular disease, cancer other than ovarian cancer, osteoporosis, cognitive impairment, and all-cause mortality. Salpingectomy at the time of hysterectomy or as a means of tubal sterilization appears to be safe and does not increase the risk of complications such as blood transfusions, readmissions, postoperative complications, infections, or fever compared with hysterectomy alone or tubal ligation. The risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization. Additionally, ovarian function does not appear to be affected by salpingectomy at the time of hysterectomy based on surrogate serum markers or response to in vitro fertilization. Plans to perform an opportunistic salpingectomy should not alter the intended route of hysterectomy. Obstetrician-gynecologists should continue to observe and practice minimally invasive techniques. This Committee Opinion has been updated to include new information on the benefit of salpingectomy for cancer reduction, the feasibility of salpingectomy during vaginal hysterectomy, and long-term follow-up of women after salpingectomy.

Effects of intratesticular vs intraepididymal calcium chloride sterilant on testicular morphology and fertility in dogs.

BACKGROUND: Both stray and free-roaming owned dogs contribute to the serious global dog overpopulation problem. Many dog owners are unwilling to have their pet castrated for various reasons, including a reluctance to have their dog's behavior changed. A non-surgical method of sterilizing both stray and owned dogs would help to prevent unwanted litters. Previous studies have shown that intratesticular injection of calcium chloride dihydrate (CaCl2) in alcohol is a promising and cost-effective alternative to surgery for stray dogs, with testosterone significantly decreased and sexual activity eliminated. The aim of this study was to compare the use of a solution of 20% CaCl2 in 95% ethanol injected into the testicles or into the head of the epididymis. METHODS: A total of 148 dogs divided into 4 groups (2 experimental and 2 control) were respectively injected with CaCl2 or saline solution into the testicle or epididymal head (ultrasound-guided). The animals were examined at 0, 3, 6, and 9 months for sperm quality, concentration of testosterone in serum, and side effects; at 0 and 5 months with contrast-enhanced ultrasound (CEUS) to enhance the morphological aspects/alteration of the testicular parenchyma or epididymis; and at 9 months when all were castrated for histological examination. RESULTS: All dogs treated with CaCl2 became sterile with azoospermia achieved over the 9-month study. The concentration of testosterone in serum significantly decreased following intratesticular treatment with CaCl2. No adverse effects were noted. CONCLUSIONS: A single, bilateral intratesticular injection of 20% CaCl2 in 95% ethanol was confirmed to be a reliable method for induction of sterilization in male dogs. The approach showed long-term efficacy and may reduce sexual behavior, with the additional benefits of low-cost and ease of use, making this nonsurgical method appropriate for use in stray dogs. Sterility was also achieved if injected in the head of the epididymis but no significant decrease in serum concentration of testosterone occurred. Moreover, performing the intraepididymal injection into the epididymal head was as time consuming as orchiectomy. This approach may be optimal for use in owned dogs where anatomical integrity and testosterone maintenance is preferred by the owner.

Optimization of irradiation dose to Aedes aegypti and Ae. albopictus in a sterile insect technique program.

The sterile insect technique (SIT) may offer a means to control the transmission of mosquito borne diseases. SIT involves the release of male insects that have been sterilized by exposure to ionizing radiation. We determined the effects of different doses of radiation on the survival and reproductive capacity of local strains of Aedes aegypti and Ae. albopictus in southern Mexico. The survival of irradiated pupae was invariably greater than 90% and did not differ significantly in either sex for either species. Irradiation had no significant adverse effects on the flight ability (capacity to fly out of a test device) of male mosquitoes, which consistently exceeded 91% in Ae. aegypti and 96% in Ae. albopictus. The average number of eggs laid per female was significantly reduced in Ae. aegypti at doses of 15 and 30 Gy and no eggs were laid by females that had been exposed to 50 Gy. Similarly, in Ae. albopictus, egg production was reduced at doses of 15 and 25 Gy and was eliminated at 35 Gy. In Ae. aegypti, fertility in males was eliminated at 70 Gy and was eliminated at 30 Gy in females, whereas in Ae. albopictus, the fertility of males that mated with untreated females was almost zero (0.1%) in the 50 Gy treatment and female fertility was eliminated at 35 Gy. Irradiation treatments resulted in reduced ovary length and fewer follicles in both species. The adult median survival time of both species was reduced by irradiation in a dose-dependent manner. However, sterilizing doses of 35 Gy and 50 Gy resulted in little reduction in survival times of males of Ae. albopictus and Ae. aegypti, respectively, indicating that these doses should be suitable for future evaluations of SIT-based control of these species. The results of the present study will be applied to studies of male sexual competitiveness and to stepwise evaluations of the sterile insect technique for population suppression of these vectors in Mexico.

The Trend, Feasibility, and Safety of Salpingectomy as a form of Permanent Sterilization.

STUDY OBJECTIVE: To assess the change in the rate of laparoscopic salpingectomy for sterilization after the release of the November 2013 Society of Gynecologic Oncology Clinical Practice Statement and the January 2015 American College of Obstetricians and Gynecologists Committee Opinion: Salpingectomy for Ovarian Cancer Prevention. We hypothesized there would be an increase in salpingectomy as a percentage of total laparoscopic sterilizations performed without an increase in complications when compared with conventional bilateral tubal ligation (BTL). DESIGN: A retrospective cohort study. SETTING: Four university-affiliated hospitals in Houston, TX, and New York, NY. PATIENTS: All women 21 years or older who underwent interval laparoscopic permanent sterilization between April 2013 and September 2016. INTERVENTIONS: Sterilization by bilateral salpingectomy or conventional tubal ligation. MEASUREMENTS AND MAIN RESULTS: There were 454 sterilization procedures identified; 60% were BTLs, whereas 40% were salpingectomies. The rate of use of salpingectomy significantly increased from 5% to 9% in 2013 to 2014 to 78% by 2016. There was no significant difference in intraoperative or postoperative complications or estimated blood loss. The mean procedure time was 54 minutes for salpingectomy compared with 45 minutes for BTL (p <.0001). Salpingectomy was more likely to require 3 ports compared with 2 ports for BTL (p <.0001). CONCLUSIONS: The Society of Gynecologic Oncology and the American College of Obstetricians and Gynecologists' support of salpingectomy for ovarian cancer prevention increased its use for sterilization. Based on this study, laparoscopic bilateral salpingectomy is a safe method of sterilization without an increase in perioperative risk compared with conventional tubal ligation. Physicians should incorporate these findings and implications when counseling patients regarding contraception and permanent sterilization.

Seven-Year Outcomes After Hysteroscopic and Laparoscopic Sterilizations.

OBJECTIVE: To evaluate 7-year outcomes after hysteroscopic and laparoscopic sterilizations, including subsequent tubal interventions and hysterectomies. METHODS: This observational cohort study included women undergoing hysteroscopic and laparoscopic sterilizations in outpatient and ambulatory surgical settings in New York State during 2005-2016. We examined subsequent procedures (tubal ligation or resection, and hysterectomy not related to uterine leiomyomas or gynecologic tumors) after the index procedures. After propensity score matching, we used Kaplan-Meier analysis to obtain estimated risks of subsequent procedures within 7 years of index sterilization procedures, and Cox proportional hazard models to compare the differences between groups. RESULTS: We identified 10,143 and 53,206 women who underwent interval hysteroscopic and laparoscopic sterilizations, respectively, in New York State during 2005-2016. The mean age of the cohort was 34.2 years (range 18-80). The propensity score-matched cohort consisted of 10,109 pairs of women. The estimated risk of undergoing an additional tubal ligation or resection within 7 years was higher after hysteroscopic sterilization than it was after laparoscopic sterilization (3.9% vs 1.6%, HR 2.89, 95% CI 2.33-3.57). The difference was most pronounced within the initial year after attempted sterilization (1.5% vs 0.2%; HR 6.39, 95% CI 4.16-9.80). There was no significant difference in the risk of receiving a hysterectomy (0.9% vs 1.2%; HR 0.73, 95% CI 0.53-1.00) between women who underwent hysteroscopic and laparoscopic sterilizations. CONCLUSION: Patients undergoing hysteroscopic sterilization have a higher risk of receiving an additional tubal resection or ligation than those undergoing laparoscopic sterilization, particularly within the first year of the index procedure. There is no difference in undergoing a subsequent hysterectomy between the two groups. With limited evidence of outcomes after hysteroscopic sterilization beyond 7 years and existing reports of removals years after initial implantations, continuous monitoring of long-term outcomes for women who received the device is warranted.

Cost-effectiveness of opportunistic salpingectomy vs tubal ligation at the time of cesarean delivery.

BACKGROUND: Removal of the fallopian tubes at the time of hysterectomy or interval sterilization has become routine practice to prevent ovarian cancer. While emerging as a strategy, uptake of this procedure at the time of cesarean delivery for pregnant women seeking permanent sterilization has not been widely adopted due to perceptions of increased morbidity and operative difficulty with a lack of available data in this setting. OBJECTIVE: We sought to conduct a cost-effectiveness analysis comparing strategies for long-term sterilization and ovarian cancer risk reduction at the time of cesarean delivery, including bilateral tubal ligation, opportunistic salpingectomy, and long-acting reversible contraception. STUDY DESIGN: A decision-analytic and cost-effectiveness model was constructed for pregnant women undergoing cesarean delivery who desired permanent sterilization in the US population, comparing 3 strategies: (1) bilateral tubal ligation, (2) bilateral opportunistic salpingectomy, and (3) postpartum long-acting reversible contraception. This theoretic cohort consisted of 110,000 pregnant women desiring permanent sterilization at the time of cesarean delivery and ovarian cancer prevention at an average of 35 years who were monitored for an additional 40 years based on an average US female life expectancy of 75 years. The primary outcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured as quality-adjusted life years. Secondary outcomes included: the number of ovarian cancer cases and deaths, procedure-related complications, and unintended and ectopic pregnancies. The 1-, 2-, and 3-way and Monte Carlo probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set at $100,000. RESULTS: Both bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery have favorable cost-effectiveness ratios. In the base case analysis, salpingectomy was more cost-effective with an incremental cost-effectiveness ratio of $23,189 per quality-adjusted life year compared to tubal ligation. Long-acting reversible contraception after cesarean was not cost-effective (ie, dominated). Although salpingectomy and tubal ligation were both cost-effective over a wide range of cost and risk estimates, the incremental cost-effectiveness ratio analysis was highly sensitive to the uncertainty around the estimates of salpingectomy cancer risk reduction, risk of perioperative complications, and cost. Monte Carlo probabilistic sensitivity analysis estimated that tubal ligation had a 49% chance of being the preferred strategy over salpingectomy. If the true salpingectomy risk of perioperative complications is >2% higher than tubal ligation or if the cancer risk reduction of salpingectomy is <52%, then tubal ligation is the preferred, more cost-effective strategy. CONCLUSION: Bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery are both cost-effective strategies for permanent sterilization and ovarian cancer risk reduction. Although salpingectomy and tubal ligation are both reasonable strategies for cesarean patients seeking permanent sterilization and cancer risk reduction, threshold analyses indicate that the risks and benefits of salpingectomy with cesarean delivery need to be better defined before a preferred strategy can be determined.

Extending the safety evidence for opportunistic salpingectomy in prevention of ovarian cancer: a cohort study from British Columbia, Canada.

BACKGROUND: Recent evidence has suggested that the fallopian tube may often be the site of origin for the most common and lethal form of ovarian cancer. As a result, many Colleges of Obstetrics and Gynecology, including the American College of Obstetricians and Gynecology, are recommending surgical removal of the fallopian tube (bilateral salpingectomy) at the time of other gynecologic surgeries (particularly hysterectomy and tubal sterilization) in women at general population risk for ovarian cancer, collectively referred to as opportunistic salpingectomy. OBJECTIVE: Previous research with the use of hospital data has indicated good perioperative safety of opportunistic salpingectomy, but no data on minor complications have been presented. Herein, we examine whether women who undergo opportunistic salpingectomy are at increased risk of minor complications after surgery. STUDY DESIGN: We identified all women in British Columbia who underwent opportunistic salpingectomy between 2008 and 2014 and examined all physician visits in the 2 weeks after discharge from the hospital. We compared women who underwent opportunistic salpingectomy at hysterectomy with women who underwent hysterectomy alone and women who underwent opportunistic salpingectomy for sterilization with women who underwent tubal ligation. We examined visits for surgical infection, surgical complication, orders for laboratory tests, and orders for imaging (x-ray, ultrasound scan, or computed tomography scan) and whether women who underwent opportunistic salpingectomy were more likely to fill a prescription for an antibiotic or analgesic in the 2 weeks after discharge from the hospital. We calculated adjusted odds ratios for these outcomes, adjusting for other gynecologic conditions, surgical approach, and patient age. RESULTS: We included 49,275 women who had undergone a hysterectomy alone, a hysterectomy with opportunistic salpingectomy, a hysterectomy with bilateral salpingo-oophorectomy, a tubal ligation, or an opportunistic salpingectomy for sterilization. In women who had undergone opportunistic salpingectomy, there was no increased risk for physician visits for surgical infection, surgical complication, ordering a laboratory test, or ordering imaging in the 2 weeks after discharge. There was no increased risk of filling a prescription for an antibiotic. However, women who underwent opportunistic salpingectomy were at approximately 20% increased odds of filling a prescription for an analgesic in the 2 weeks after discharge from the hospital (adjusted odds ratio, 1.23; 95% confidence interval, 1.15-1.32 for hysterectomy with opportunistic salpingectomy; adjusted odds ratio, 1.21; 95% confidence interval, 1.14-1.29 for opportunistic salpingectomy for sterilization). CONCLUSION: We report no differences in minor complications between women who undergo opportunistic salpingectomy and women who undergo hysterectomy alone or tubal ligation, except for a slightly increased likelihood of filling a prescription for analgesic medication in the immediate 2 weeks after discharge.

Surgical Management After Hysteroscopic Sterilization: Minimally Invasive Approach Incorporating Intraoperative Fluoroscopy for Symptomatic Patients with >2 Essure® Devices.

OBJECTIVE: To describe a non-hysterectomy surgical technique for symptomatic patients with >2 Essure® (Bayer Healthcare, Whippany, New Jersey) devices. DESIGN: Patients (n=4) presented with sharp pelvic pain, irregular vaginal bleeding, dyspareunia, weight gain, hair loss, fatigue, and/or diffuse skin rash, all of which were absent before undergoing hysteroscopic sterilization (HS). Hysterosalpingogram obtained before surgical excision of contraceptive tubal implants confirmed more than two Essure® devices in all patients. Except for HS-associated complaints, all patients were in otherwise good general health and none had any history of prior pelvic pathology. Hysteroscopy was followed by 5mm triple-port laparoscopic cornual dissection, modified partial bilateral salpingectomy, and foreign body removal under fluoroscopy and/or radiographic guidance. RESULTS: In this group, mean±SD patient age was 41±8yrs and interval between HS and device removal was 6.4±2.7yrs. At the conclusion of each case (mean±SD operative time=179±11min), imaging studies were reviewed by an attending radiologist and verified no retained metal in the abdomen. Conversion to laparotomy, hysterectomy, or blood transfusion was unnecessary for any patients, and all were discharged home within three hours. Their postoperative course continues to be satisfactory. CONCLUSION: Patients with more than two Essure® devices comprise an unusual group with a complex pelvic foreign body presentation. This is the first report on surgical management for such patients, underscoring the importance of localizing these contraceptive devices with careful imaging before, during, and after surgery. Moreover, hysterectomy is not absolutely mandatory in this setting and intraoperative fluoroscopy/radiography can facilitate complete, safe removal of all implants on an out-patient basis. Creation of ICD-10 modifiers for various post-HS complaints would allow for improved surveillance of the Essure® phenomenon.

Population Control in Small Animals.

Optimal age for ovariohysterectomy or castration has not been defined in the scientific literature. Bitches and queens are significantly less likely to develop mammary neoplasia, which has a high incidence and potentially high morbidity and mortality, if spayed when young. Tom cats exhibit undesirable behaviors that preclude them being good pets and should be castrated young. There is no compelling reason to castrate male dogs when young unless it is needed to control reproductive behaviors or prevent indiscriminate breeding. Alternatives to surgical sterilization that may be available in the future include intratesticular injection and immunization against gonadotropin-releasing hormone.

Esterilização tubária histeroscópica: uma atualização sobre o dispositivo Essure® / Hysteroscopic tubal sterilization: update on the Essure® device

No intuito de oferecer para a laqueadura tubária uma alternativa menos invasiva e com menos complicações, foi desenvolvido o dispositivo Essure®, aplicado ao método da esterilização histeroscópica, além de ter utilidade nos quadros de hidrossalpinge com indicação de fertilização in vitro (FIV). Este artigo, por meio de uma revisão de literatura, teve como objetivo reunir dados acerca do uso do Essure®, incluindo resultados obtidos com o dispositivo, bem como comparações em diversos aspectos com outras metodologias de esterilização. Foram utilizados os bancos de dados PubMed, Lilacs e Scielo, no período entre 1970 e 2016. Foram pesquisados os termos "hysteroscopic contraception"; "Essure"; "definitive tubal sterilization; "sterilization"; "contraception". A literatura demonstrou se tratar de um dispositivo de fácil e rápida inserção, e com bons resultados para anticoncepção. Porém, devido a complicações como perfuração tubária, implante peritoneal e aborto, bem como para avaliar seu custo financeiro ao sistema de Saúde, mais estudos prospectivos são necessários.(AU)

In order to provide a less invasive and harmful technique compared to the tubal ligation, the Essure® device was developed, applied to the hysteroscopic sterilization method. It is also used in cases of hydrosalpinus and indication of in vitro fertilization (IVF). This article, through a literature review, aimed to gather data about the use of Essure®, including results obtained with the device, comparing different aspects with other methods of sterilization. For this purpose, PubMed, Lilacs and Scielo databases were used, with results from 1970 to 2016. The keywords searched were "hysteroscopic contraception", "Essure", "definitive tubal sterilization". The literature has shown that it is a quickly and easily inserted device with good results for contraception. However, due to complications such as tubal perforation, peritoneal implantation and abortion, as well as to evaluate its financial cost to the health system, more prospective studies are needed.(AU)