Investigating Barriers to Completion of Postpartum Tubal Ligation: A Retrospective Chart Review.

OBJECTIVES: To identify the completion rate for postpartum tubal ligation (PPTL) and predictors of noncompletion of PPTL in a central New Jersey population. METHODS: We conducted a retrospective chart review at a tertiary care center in New Jersey for patients delivering during an 18-month period. We used the electronic medical record to identify all of the patients who had documented desire for a PPTL at the time of admission. We calculated the rate of PPTL completion and identified predictors of completion and risk factors for noncompletion. We recorded any documented reasons for cancellation and choice of contraception after noncompletion. RESULTS: Of 626 women who requested PPTL on admission, 508 (81.2%) procedures were performed. The most common reasons for noncompletion were patient changing her mind (38.1%) and unknown/not documented (22.9%). Cesarean delivery was the strongest predictor of completion, with 93.4% completion among cesarean deliveries compared with 65.6% among vaginal deliveries (P < 0.01). Lack of insurance also was associated with noncompletion (P < 0.01). There was no difference in body mass index (P = 0.75), gravidity (P = 0.99), parity (P = 0.72), or high-risk status (P = 0.47) between completed and noncompleted PPTL. CONCLUSIONS: Cesarean delivery is a strong predictor of PPTL completion, most likely because of easier availability of the operating room, anesthesia, and ancillary staff. Body mass index, gravidity, and parity are not associated with PPTL completion. Future research should focus on exploring whether this association is system, provider, or patient dependent.

Postpartum Salpingectomy Compared With Standard Tubal Ligation After Vaginal Delivery.

OBJECTIVE: To compare operative outcomes of postpartum salpingectomy and tubal ligation after vaginal delivery. METHODS: This retrospective cohort study identified patients who underwent tubal sterilization between January 1, 2009, and December 31, 2019, at a large academic hospital, using the electronic medical record. All patients who delivered vaginally and underwent tubal sterilization during their delivery admissions were included. The primary outcome was total operative time. Secondary outcomes included estimated blood loss, perioperative complications, and readmission within 6 weeks postpartum. Patients who underwent bilateral tubal ligation were compared with those who underwent bilateral salpingectomy using Pearson's χ2 test, Fisher exact, and Student's t test. RESULTS: A total of 317 eligible patients were identified. One hundred and six (94%) salpingectomies were completed using a bipolar electrocautery device. Operative time was 3 minutes shorter in the salpingectomy group, 30 minutes (interquartile range 24-38) compared with 33.5 (26-42) minutes, P=.032. Patients who underwent salpingectomy were more likely to have estimated blood loss of 5 mL or less (our institutional shorthand for minimal blood loss) than women who underwent bilateral tubal ligation (78 [69%] vs 112 [55%], P=.015). There were no significant differences in perioperative complications between the groups. CONCLUSION: When using electrocautery, bilateral salpingectomy can be completed in the immediate postpartum period after vaginal delivery with equivalent operative times to bilateral tubal ligation.

Surgical treatment for tubal disease in women due to undergo in vitro fertilisation.

BACKGROUND: Tubal disease accounts for 20% of infertility cases. Hydrosalpinx, caused by distal tubal occlusion leading to fluid accumulation in the tube(s), is a particularly severe form of tubal disease negatively affecting the outcomes of assisted reproductive technology (ART). It is thought that tubal surgery may improve the outcome of ART in women with hydrosalpinges. OBJECTIVES: To assess the effectiveness and safety of tubal surgery in women with hydrosalpinges prior to undergoing conventional in vitro fertilisation (IVF) or intracytoplasmic sperm injection (ICSI). SEARCH METHODS: We searched the Cochrane Gynaecology and Fertility (CGF) Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, DARE, and two trial registers on 8 January 2020, together with reference checking and contact with study authors and experts in the field to identify additional trials. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing surgical treatment versus no surgical treatment, or comparing surgical interventions head-to-head, in women with tubal disease prior to undergoing IVF. DATA COLLECTION AND ANALYSIS: We used Cochrane's standard methodological procedures. The primary outcomes were live birth rate (LBR) and surgical complication rate per woman randomised. Secondary outcomes included clinical, multiple and ectopic pregnancy rates, miscarriage rates and mean numbers of oocytes retrieved and of embryos obtained. MAIN RESULTS: We included 11 parallel-design RCTs, involving a total of 1386 participants. The included trials compared different types of tubal surgery (salpingectomy, tubal occlusion or transvaginal aspiration of hydrosalpingeal fluid) to no tubal surgery, or individual interventions to one another. We assessed no studies as being at low risk of bias across all domains, with the main limitations being lack of blinding, wide confidence intervals and low event and sample sizes. We used GRADE methodology to rate the quality of the evidence. Apart from one moderate-quality result in one review comparison, the evidence provided by these 11 trials ranged between very low- to low-quality. Salpingectomy versus no tubal surgery No included study reported on LBR for this comparison. We are uncertain of the effect of salpingectomy on surgical complications such as the rate of conversion to laparotomy (Peto odds ratio (OR) 5.80, 95% confidence interval (CI) 0.11 to 303.69; one RCT; n = 204; very low-quality evidence) and pelvic infection (Peto OR 5.80, 95% CI 0.11 to 303.69; one RCT; n = 204; very low-quality evidence). Salpingectomy probably increases clinical pregnancy rate (CPR) versus no surgery (risk ratio (RR) 2.02, 95% CI 1.44 to 2.82; four RCTs; n = 455; I2 = 42.5%; moderate-quality evidence). This suggests that in women with a CPR of approximately 19% without tubal surgery, the rate with salpingectomy lies between 27% and 52%. Proximal tubal occlusion versus no surgery No study reported on LBR and surgical complication rate for this comparison. Tubal occlusion may increase CPR compared to no tubal surgery (RR 3.21, 95% CI 1.72 to 5.99; two RCTs; n = 209; I2 = 0%; low-quality evidence). This suggests that with a CPR of approximately 12% without tubal surgery, the rate with tubal occlusion lies between 21% and 74%. Transvaginal aspiration of hydrosalpingeal fluid versus no surgery No study reported on LBR for this comparison, and there was insufficient evidence to identify a difference in surgical complication rate between groups (Peto OR not estimable; one RCT; n = 176). We are uncertain whether transvaginal aspiration of hydrosalpingeal fluid increases CPR compared to no tubal surgery (RR 1.67, 95% CI 1.10 to 2.55; three RCTs; n = 311; I2 = 0%; very low-quality evidence). Laparoscopic proximal tubal occlusion versus laparoscopic salpingectomy We are uncertain of the effect of laparoscopic proximal tubal occlusion versus laparoscopic salpingectomy on LBR (RR 1.21, 95% CI 0.76 to 1.95; one RCT; n = 165; very low-quality evidence) and CPR (RR 0.81, 95% CI 0.62 to 1.07; three RCTs; n = 347; I2 = 77%; very low-quality evidence). No study reported on surgical complication rate for this comparison. Transvaginal aspiration of hydrosalpingeal fluid versus laparoscopic salpingectomy No study reported on LBR for this comparison, and there was insufficient evidence to identify a difference in surgical complication rate between groups (Peto OR not estimable; one RCT; n = 160). We are uncertain of the effect of transvaginal aspiration of hydrosalpingeal fluid versus laparoscopic salpingectomy on CPR (RR 0.69, 95% CI 0.44 to 1.07; one RCT; n = 160; very low-quality evidence). AUTHORS' CONCLUSIONS: We found moderate-quality evidence that salpingectomy prior to ART probably increases the CPR compared to no surgery in women with hydrosalpinges. When comparing tubal occlusion to no intervention, we found that tubal occlusion may increase CPR, although the evidence was of low quality. We found insufficient evidence of any effect on procedure- or pregnancy-related adverse events when comparing tubal surgery to no intervention. Importantly, none of the studies reported on long term fertility outcomes. Further high-quality trials are required to definitely determine the impact of tubal surgery on IVF and pregnancy outcomes of women with hydrosalpinges, particularly for LBR and surgical complications; and to investigate the relative efficacy and safety of the different surgical modalities in the treatment of hydrosalpinges prior to ART.

Results of the Insertion of Hysteroscopic Sterilization Devices in a Brazilian Public Hospital.

OBJECTIVE: To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility. METHODS: Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics. RESULTS: In 85.8% of the cases, the uterine cavity was normal, and the most commonly-described findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56 minutes (range: 1 to 10 minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%). CONCLUSION: Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

OBJETIVO: Avaliar a inserção de dispositivo intratubário de esterilização histeroscópica com relação à viabilidade e à técnica. MéTODOS: Estudo retrospectivo com coleta de dados de prontuários das pacientes submetidas à inserção do dispositivo entre janeiro e setembro de 2016 em um hospital público do Rio de Janeiro, com análise dos dados e realização de estatísticas descritivas. RESULTADOS: Foram incluídos 904 casos no estudo. Em 85,8% dos casos, a cavidade uterina estava normal, e os achados mais comumente descritos à histeroscopia foram as sinequias (9,5%). O tempo médio do procedimento foi de 3,56 minutos (gama: de 1 a 10 minutos); a dor foi considerada de ausente a leve em 58,6% dos casos, de leve a moderada em 32,8% dos casos, e de forte à pior dor possível em menos de 1% dos casos (0,8%). A taxa de inserções bem-sucedidas foi de 85,0%, e a colocação tubária foi bem-sucedida em 99,5% dos casos. Não foram identificadas complicações graves, mas reações vasovagais transitórias ocorreram em 5 mulheres (0,6%). CONCLUSãO: A esterilização feminina por histeroscopia é um procedimento seguro, viável, rápido, e bem tolerado. As taxas de inserção bem-sucedida e de colocação tubária foram altas. Houve poucos e leves efeitos colaterais durante o procedimento, e não foram observadas complicações graves no curto prazo.

Examining the Association of Obesity With Postpartum Tubal Ligation.

OBJECTIVE: To evaluate the association of increasing body mass index (BMI) on postpartum tubal ligation safety and estimate the rates of procedure complication. METHODS: We conducted a single-institution, retrospective review. Women undergoing postpartum permanent contraception after vaginal delivery from August 2015 to March 2019 were studied. Our primary outcome included a composite morbidity of intraoperative complications (bleeding requiring additional surgery, and extension of incision), blood transfusion, aborted procedure, anesthetic complication, readmission, wound infection, venous thromboembolism, ileus or small bowel obstruction, incomplete transection, and subsequent pregnancy. Statistical analysis included t test, χ test, and Wilcoxon rank-sum test, with P<0.05 considered significant. RESULTS: During the study period, 3,670 women were studied: 263 were underweight or normal weight (BMI 24.9 or lower), 1,044 were overweight (25-29.9), 1,371 had class I obesity (30-34.9), 689 had class II obesity (35-39.9), and 303 had class III obesity (40 or higher) at the time of admission. Composite morbidity occurred in 49 cases (1.3%) and was not significantly different across the BMI categories (P=.07). Twelve cases of incomplete transection were noted on pathology reports; however, none of these accounted for the six subsequent pregnancies that were identified. There were no deaths or events leading to death noted in the study population. The length of time to complete the procedure increased across BMI categories (23 minutes in women with normal weight, and 31 in women with class III obesity) (P<.001). CONCLUSION: There was no association between increased BMI and morbidity with women undergoing postpartum tubal ligation. Postpartum tubal ligation should be considered a safe and reasonable option for women, regardless of BMI.

Results of the insertion of hysteroscopic sterilization devices in a brazilian public hospital / Resultados da inserção de dispositivos de esterilização histeroscópica em um hospital público brasileiro

Abstract Objective To evaluate the insertion of the hysteroscopic intratubal sterilization device for female sterilization concerning the technique and the feasibility. Methods Retrospective study with data collection of medical records of 904 patients who underwent device insertion between January and September 2016 in a public hospital in Rio de Janeiro (Brazil) with data analysis and descriptive statistics. Results In 85.8% of the cases, the uterine cavity was normal, and themost commonlydescribed findings upon hysteroscopy were synechiae (9.5%). The procedure lasted an average of 3.56minutes (range: 1 to 10minutes), and the pain was considered inexistent or mild in 58,6% of the cases, mild or moderate in 32,8%, and severe or agonizing in less than 1% (0.8%) of the cases, based on a verbal scale ranging from 0 to 10. The rate of successful insertions was of 85.0%, and successful tubal placement was achieved in 99.5% of the cases. There were no severe complications related to the procedure, but transient vasovagal reactions occurred in 5 women (0.6%). Conclusion Female sterilization performed by hysteroscopy is a safe, feasible, fast, and well-tolerated procedure. The rates of successful insertions and tubal placements were high. There were few and mild adverse effects during the procedure, and there were no severe complications on the short term.

Resumo Objetivo Avaliar a inserção de dispositivo intratubário de esterilização histeroscópica com relação à viabilidade e à técnica. Métodos Estudo retrospectivo com coleta de dados de prontuários das pacientes submetidas à inserção do dispositivo entre janeiro e setembro de 2016 emumhospital público do Rio de Janeiro, comanálise dos dados e realização de estatísticas descritivas. Resultados Foram incluídos 904 casos no estudo. Em 85,8% dos casos, a cavidade uterina estava normal, e os achados mais comumente descritos à histeroscopia foram as sinequias (9,5%). O tempomédio do procedimento foi de 3,56minutos (gama: de 1 a 10 minutos); a dor foi considerada de ausente a leve em 58,6% dos casos, de leve a moderada em32,8% dos casos, e de forte à pior dor possível emmenos de 1% dos casos (0,8%). A taxa de inserções bem-sucedidas foi de 85,0%, e a colocação tubária foi bemsucedida em 99,5% dos casos. Não foram identificadas complicações graves, mas reações vasovagais transitórias ocorreram em 5 mulheres (0,6%). Conclusão A esterilização feminina por histeroscopia é um procedimento seguro, viável, rápido, e bem tolerado. As taxas de inserção bem-sucedida e de colocação tubária foram altas. Houve poucos e leves efeitos colaterais durante o procedimento, e não foram observadas complicações graves no curto prazo.

Laparoscopic Essure® Device Removal by En Bloc Salpingectomy-Cornuectomy with Intraoperative X-Ray Checking: A Retrospective Cohort Study.

STUDY OBJECTIVE: To evaluate the feasibility, efficacy, and morbidity of Essure® device removal via laparoscopic en bloc salpingectomy-cornuectomy resection (LSC) and the utility of confirmation of complete removal with an intraoperative X-ray of the removed specimen (IX-S). DESIGN: Retrospective observational cohort study. SETTING: Academic hospitals of La Conception, Marseille, and Arnaud-de-Villeneuve, Montpellier, France. PATIENTS: Women who were not seeking future fertility seeking Essure® device removal by salpingectomy, between February 2017 and August 2018. INTERVENTIONS: All women underwent LSC. An IX-S was performed to confirm complete Essure® device removal. In the case of an unsatisfactory IX-S, an intraoperative pelvic X-ray control of the patient (IX-P) was performed. If IX-P diagnosed residual Essure® fragments, an additional resection was performed, and the removed tissue was checked by IX-S. MEASUREMENTS AND MAIN RESULTS: We included 72 women, and a total of 140 Essure® devices were removed. The IX-S confirmed complete Essure® device removal in 131 of 140 cases (93.6%) in 63 of 72 women (87.5%). Out of the 9 women with unsatisfactory IX-S, 6 had no residual Essure® fragments at IX-P, and Essure® device removal was considered complete. Three women had a persistent Essure® fragment at IX-P: an additional resection allowed complete removal in 2 cases and resulted in failure in 1 of 140 case (0.7%). There were 2 of 72 women (2.8%) intraoperative complications and 4 of 72 women (5.6%) postoperative grade 1 complications according to the Clavien-Dindo classification. CONCLUSION: Essure® device removal by LSC appears to be an effective and safe procedure. IX-S is a useful method to evaluate whether the removal of Essure® device is complete during an LSC procedure.

Analysis of pregnancy outcome after anastomosis of oviduct and its influencing factors.

BACKGROUND: This study aims to investigate the influencing factors of pregnancy after laparoscopic oviduct anastomosis. METHODS: The data of 156 cases of laparoscopic oviduct anastomosis in our hospital were analyzed. RESULTS: The pregnancy rate decreased with age (P < 0.005). The pregnancy rate after six years of anastomosis was higher in those with ligation (P < 0.005). The postoperative pregnancy rate significantly increased in subjects with oviduct lengths of > 7 cm (P < 0.01). The pregnancy rate of isthmus end-to-end anastomosis was higher (P < 0.005). The pregnancy rate after bilateral tubal recanalization was higher than that after unilateral tubal recanalization (P < 0.005). The pregnancy rate after laparoscopic tubal ligation and laparoscopic anastomosis was higher than that of open tubal ligation and laparoscopic anastomosis (P < 0.005). CONCLUSION: The pregnancy rate after laparoscopic oviduct anastomosis is higher in subjects below 35 years old, with a ligation duration of < 6 years, and a length of oviduct of > 7 cm, and those who underwent isthmus anastomosis and laparoscopic oviduct ligation and recanalization.

Desired Sterilization Procedure at the Time of Cesarean Delivery According to Insurance Status.

OBJECTIVE: To evaluate whether women with Medicaid are less likely than their privately insured counterparts to receive a desired sterilization procedure at the time of cesarean delivery. METHODS: This is a secondary analysis of a single-center retrospective cohort examining 8,654 postpartum women from 2012 to 2014, of whom 2,205 (25.5%) underwent cesarean delivery. Insurance was analyzed as Medicaid compared with private insurance. The primary outcome was sterilization at the time of cesarean delivery. Reason for sterilization noncompletion and Medicaid sterilization consent form validity were recorded. Secondary outcomes included postpartum visit attendance, outpatient postpartum sterilization, and subsequent pregnancy within 365 days of delivery. RESULTS: Of the 481 women included in this analysis, 78 of 86 (90.7%) women with private insurance and 306 of 395 (77.4%) women with Medicaid desiring sterilization obtained sterilization at the time of cesarean delivery (relative risk 0.85, 95% CI 0.78-0.94). After multivariable logistic regression, gestational age at delivery (1.02 [1.00-1.03]), adequacy of prenatal care (1.30 [1.18-1.43]), and marital status (1.09 [1.01-1.19]) were associated with achievement of sterilization at the time of cesarean delivery. Sixty-four (66.0%) women who desired but did not receive sterilization at the time of cesarean delivery did not have valid, signed Medicaid sterilization forms, and 10 (10.3%) sterilizations were not able to be completed at the time of surgery owing to adhesions. Sterilization during cesarean delivery was not associated with less frequent postpartum visit attendance for either the Medicaid or privately insured population. Rates of outpatient postpartum sterilization were similar among those with Medicaid compared with private insurance. Among patients who did not receive sterilization at the time of delivery, 15 patients (each with Medicaid) had a subsequent pregnancy within the study period. CONCLUSION: Women with Medicaid insurance received sterilization at the time of cesarean delivery less frequently than privately insured counterparts, most commonly due to the absence of a valid Medicaid sterilization consent form as well as adhesive disease. The constraints surrounding the Medicaid form serve as a significant barrier to achieving desired sterilization.

Expedited Scheduling of Interval Tubal Ligation: A Randomized Controlled Trial.

OBJECTIVE: To assess whether expedited scheduling for permanent contraception increases the proportion of patients completing interval tubal ligation within 6 months of delivery. METHODS: We randomly assigned patients with unfulfilled immediate postpartum tubal ligation requests to standard scheduling after a postpartum office visit or an expedited process in which we scheduled the interval tubal ligation surgery before discharge from the hospital. The primary outcome was proportion of participants undergoing tubal contraceptive procedures within 6 months of delivery. Secondary outcomes included patient satisfaction with the scheduling process, repeat pregnancy rates, and surgical outcomes. We estimated that 122 patients (61 per group) would provide greater than 80% power to identify a 25% difference favoring expedited scheduling in the primary outcome (one-sided α of 0.05). RESULTS: Between September 2016 and June 2018, 239 patients requested tubal ligation at the time of delivery; 155 were not completed. Of these, 126 patients were eligible for the study. We stopped the study at the prespecified 50% enrollment point after 67 patients enrolled, with 34 and 33 assigned to the standard and expedited arms, respectively. Fifteen participants in the expedited group, and two in the standard group completed tubal ligation within 6 months (50% vs 9%; odds ratio 10.0, CI 2.0-50.2). Delivery-to-surgery interval was 49 days in the expedited group, compared with 121 days in the standard group (P=.05). Seventeen participants in the expedited group and three in the standard group reported being very satisfied with the scheduling process (57% vs 13%, P=.03). The only two interim pregnancies both occurred in the standard group (P=.09). There were no surgical complications in any of the 17 completed tubal procedures. CONCLUSION: Expedited scheduling significantly improves tubal contraceptive surgery completion and patient satisfaction. Laparoscopic or hysteroscopic tubal ligation or salpingectomy can be performed 4-6 weeks after delivery with minimal interval outpatient follow-up. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT02875483.

Assessment of Contraceptive Counseling and Contraceptive Use in Women After Bariatric Surgery.

BACKGROUND: Reproductive-aged women are, according to American and European guidelines, recommended to avoid pregnancy for 12-24 months after bariatric surgery. Oral contraceptives may have suboptimal efficacy after malabsorptive bariatric procedures. AIM: The aim of this study was to assess contraceptive use pre- and postoperatively in women who underwent bariatric surgery in two obesity clinics in The Netherlands. Also, the recall of contraceptive and pregnancy counseling was investigated. METHODS: A validated questionnaire was performed among women aged 18-45 years who underwent bariatric surgery from October 2017 through August 2018. RESULTS: In total, 230 women were eligible for final analysis. Postoperatively, 60% used safe contraception, 16.1% unsafe contraception, and 23.9% no contraception. In this study, 43.7% of women using a potential unsafe contraceptive method preoperatively switched to a safe method of contraception postoperatively (p < 0.0001). Only 62.6% of women confirmed to have received contraceptive counseling, mainly preoperatively. The odds ratio for receiving contraceptive counseling and using safe contraceptive methods compared with not receiving contraceptive counseling was 2.20 (95% CI, 1.27-3.79; p = 0.005). Eighty-three percent confirmed that they have received counseling regarding delaying a pregnancy, and 52.6% were familiar with the recommendation to avoid a pregnancy for 24 months postoperatively. CONCLUSIONS: In our study, 60% of women are using safe contraception postoperatively. Contraceptive counseling is suboptimal as 62.6% recall receiving counseling. Those who confirmed receiving counseling were more likely to use safe contraception after bariatric surgery. More counseling and monitoring in the postoperative and in the outpatient setting is recommended.

Tubal Ligation and Age at Natural Menopause.

OBJECTIVE: To determine the effect of tubal ligation on age at natural menopause, as a marker of long-term ovarian function. METHODS: Three preexisting population-based cohorts were included in this cross-sectional study. Data from each cohort was analyzed separately. The cohorts were restricted to women who never smoked and had reached natural menopause, without prior hysterectomy or oophorectomy. The following variables were collected: race, age at menarche, age at menopause, history of hysterectomy or oophorectomy, gravidity and parity, tobacco use, and ever use of hormonal contraception. The type of tubal ligation and age at tubal ligation were manually abstracted in cohort 1. For cohorts 2 and 3, history of tubal ligation was obtained from an institutional form, completed by patient report. The primary outcome, age at natural menopause, was compared between the two groups (those with and without a history of tubal ligation). RESULTS: Inclusion criteria was met by 555 women from cohort 1, 1,816 women from cohort 2, and 1,534 women from cohort 3. Baseline characteristics did not differ between cohorts. The percentage with tubal ligation was the same in all cohorts: 26.0%, 25.5%, and 25.0%, respectively. Women with a tubal ligation were more likely to have had at least one pregnancy and to have used hormonal contraception compared with women without a tubal ligation. There was no significant difference in age at natural menopause in women who underwent tubal ligation (50.1, 49.9, 50.0 years, respectively) compared with those who did not (50.7, 49.6, 50.0 years, respectively). The type of tubal ligation (cohort 1 only) had no effect on age at menopause. CONCLUSIONS: Tubal ligation did not affect age at natural menopause in the three large cohorts included in this study.

Relationship between body mass index and operative time in women receiving immediate postpartum tubal ligation.

OBJECTIVES: The aim of the study was to (1) assess the relationship between body mass index (BMI) and operative time during immediate postpartum tubal ligation procedures and to (2) determine whether operative time is non-inferior in women with BMI ≥30 versus women with BMI <30 and in women with BMI ≥40 versus women with BMI <40. STUDY DESIGN: We conducted a retrospective cohort study of women who received immediate postpartum tubal ligations following vaginal delivery from 2013 to 2017 at a university hospital. We abstracted demographic information, patient and procedural characteristics, and clinical outcomes. We assessed the relationship between BMI and operative time via linear regression. We also conducted non-inferiority analysis to determine whether the mean operative time in women with BMI ≥30 was non-inferior to the mean operative time in women with BMI <30, within a non-inferiority margin of 10 min. We compared intraoperative and postoperative complications in the two groups. RESULTS: A total of 279 women were included for analysis, among whom N=79 (28%) had a BMI of 25-29.9 and N=171 (61%) had a BMI ≥30. Demographic characteristics were similar in both groups. We found that operative time increased by 35 s for each one-point increase in BMI (p<.01). Although mean operative time was 46.1 min (n=171; 95% CI 43.7, 48.6 min) for women with BMI ≥30 and 40.6 min (n=108; 95% CI 37.9 min, 43.4 min) for women with BMI <30, (p<.01), it was non-inferior within a 10-min margin. There was no difference in rates of intraoperative or postoperative complications, incision length, total anesthesia time, and median length of stay between women with BMI ≥30 and BMI <30. CONCLUSION: There is a small increase in postpartum tubal ligation operative time with increasing BMI. However, among women who received immediate postpartum tubal ligations at our institution, women with BMI ≥30 versus BMI <30 had operative times that were non-inferior within a 10-min margin. IMPLICATIONS: While increasing body mass index slightly increases the operative time for immediate postpartum tubal ligations, this increase in time does not appear to be clinically significant.

Social inequalities in the use of contraceptives in adult women from Southern Brazil.

OBJECTIVE: To describe the contraceptive methods used by adult women and the associated socioeconomic and demographic factors. METHODS: Population-based cross-sectional study with 20 to 49-year-old women from São Leopoldo, state of Rio Grande do Sul, in 2015. Three outcomes were considered to analyze the association with demographic and socioeconomic characteristics: use of oral contraceptive pills, tubal ligation and male condom. The crude prevalence ratios, stratified by age, and 95% confidence intervals (95%CI) were obtained using Poisson regression, taking the experimental error into account. RESULTS: A total of 736 women, aged from 20 to 49 years old, were evaluated. The prevalence of the use of oral contraceptive pills, tubal ligation and male condom were respectively 31.8% (95%CI 28.4-35.3), 11.1% (95%CI 9.0-13.6) and 10.9% (95%CI 8.7-13.3). In addition, 10.5% (n = 77) of the women reported making combined use of oral contraceptive pills and condom. In the stratified analysis, younger women with lower education level and from lower social classes reported less use of oral contraceptive pills. Tubal ligation was more prevalent among the lower social classes, but only in the age group from 30 to 39 years old. No differences were found in relation to male condom. CONCLUSIONS: The results indicated that differences persist in relation to contraception, which can be associated with both the difficulties of access to these inputs and the frailty of actions in reproductive health to achieve the needs and preferences of women who are more socially vulnerable.

Racial and Ethnic Disparities in Desire for Reversal of Sterilization Among U.S. Women.

Purpose: Racial and ethnic disparities in rates of female sterilization, a prominent method of contraception, have been consistently observed for decades. Such disparities are also evident in subsequent desire for reversal of the procedure. Additional work is needed to better understand these patterns, particularly given the historical context of coercive sterilization patterns in minority and low-income women. Materials and Methods: Two cycles of the National Survey of Family Growth data are pooled (2011-2013 and 2006-2010) and used to estimate odds ratios (ORs) for race and ethnicity, controlling for payment method, age at sterilization, number of long-term partners, and other known covariates. Results: After adjusting for other factors, the odds of desire for reversal were 70% higher (OR 1.70, confidence interval [95% CI] 1.26-2.29) in non-Hispanic (NH) Black and 54% (OR 1.54, 95% CI 1.14-2.08) in Hispanic women compared to their NH White counterparts. In addition, the likelihood of desire for reversal was substantially increased with lower age at sterilization, a higher number of partners, and lower education. Conclusions: Robust findings of desire for reversal among racial and ethnic minorities, taken together with increased desire for reversal on the basis of specific personal characteristics, merit attention to the possibility that disproportionate outcomes reflect a lack of access to desired contraception and an inability to achieve desired fertility goals in marginalized populations.

Reproductive health care in Catholic-owned hospitals.

Mergers that affiliate a hospital with a Catholic owner, network, or system reduce the set of possible reproductive medical procedures since Catholic hospitals have strict prohibitions on contraception. Using changes in ownership of hospitals, we find that Catholic hospitals reduce the per bed rates of tubal ligations by 31%, whereas there is no significant change in related permitted procedures such as Caesarian sections. However, across a variety of measures, we find minimal overall welfare reductions. Still, fewer tubal ligations increase the risk of unintended pregnancies across the United States, imposing a potentially substantial cost for less reliable contraception on women and their partners.

Factores asociados a la no realización de la esterilización quirúrgica en mujeres gran multíparas de la serranía peruana, 2017 / Factors associated with not performing surgical sterilization in great multiparous women of the Peruvian highlands, 2017

RESUMEN Objetivo: Determinar las características sociodemográficas, los antecedentes gíneco-obstétricos, la percepción y los conocimientos previos asociados a no realizarse la esterilización quirúrgica en mujeres gran multíparas internadas en un hospital de la provincia de Huancayo. Materiales y Métodos: Estudio de tipo cuantitativo, prospectivo y de corte transversal, que se realizó en las mujeres gran multíparas internadas en el Hospital Regional Docente Materno Infantil "El Carmen" de Huancayo; que cumplieran con los criterios de inclusión. Se aplicó un instrumento de recolección de tipo encuesta. Se realizó una estadística descriptiva, así como, el análisis bivariado y multivariado. Resultados: Un 73% de las mujeres encuestadas no se realizaría la esterilización quirúrgica a futuro, sin embargo, a un 90% le gustaría recibir más información al respecto. Los factores estadísticamente significativos asociados a no realizase la esterilización quirúrgica fueron: No haber utilizado ningún método anticonceptivo anteriormente (RPa: 1,35; IC 95%: 1,01-1,82; p: 0,042), no saber si desea tener más hijos (RPa: 1,58; IC 95%: 1,22-2,03; p <0,001), pensar que realizarse la esterilización quirúrgica iría en contra de sus derechos (RPa: 1,24; IC 95%:1,05-1,46; p: 0,008) y pensar que la esterilización quirúrgica produce alteraciones menstruales (RPa: 1,11; IC 95%:1,17-1,34; p: 0,027). Conclusiones: Muchas mujeres encuestadas no optarían por la esterilización quirúrgica a futuro, debido a diversos factores, muchos de ellos modificables con una adecuada capacitación e intervención del personal de salud.

ABSTRACT Objective: Determine sociodemographic characteristics, gynecological-obstetric history, perception and previous knowledge associated with not performing surgical sterilization in large multiparous women admitted to a hospital in the province of Huancayo. Materials and Methods: A quantitative, prospective and cross-sectional study, was carried out on large multiparous women hospitalized in the gynecology and obstetrics services of the Regional Maternal and Child Teaching Hospital "El Carmen" of Huancayo; that met the inclusion criteria. A survey-type collection instrument was applied. A descriptive statistic was carried out, as well as the bivariate and multivariate analysis. Results: 73% of the women surveyed would not undergo surgical sterilization in the future, however, 90% would like to receive more information about it. The statistically significant factors associated with not performing surgical sterilization were: Not having used any contraceptive method previously (RPa: 1.35, 95% CI: 1.01-1.82, p: 0.042), not knowing if you want having more children (RPa: 1.58, 95% CI: 1.22-2.03, p <0.001), thinking that performing surgical sterilization would be against their rights (RPa: 1.24, 95% CI: 1.05-1.46; p: 0.008) and to think that surgical sterilization produces menstrual alterations (RPa: 1.11, 95% CI: 1.17-1.34, p: 0.027). Conclusions: Many women surveyed would not opt for surgical sterilization in the future due to various factors, many of them modifiable with adequate training and intervention of health personnel.

Social inequalities in the use of contraceptives in adult women from Southern Brazil / Desigualdades sociais no uso de contraceptivos em mulheres adultas no Sul do Brasil

ABSTRACT OBJECTIVE: To describe the contraceptive methods used by adult women and the associated socioeconomic and demographic factors. METHODS: Population-based cross-sectional study with 20 to 49-year-old women from São Leopoldo, state of Rio Grande do Sul, in 2015. Three outcomes were considered to analyze the association with demographic and socioeconomic characteristics: use of oral contraceptive pills, tubal ligation and male condom. The crude prevalence ratios, stratified by age, and 95% confidence intervals (95%CI) were obtained using Poisson regression, taking the experimental error into account. RESULTS: A total of 736 women, aged from 20 to 49 years old, were evaluated. The prevalence of the use of oral contraceptive pills, tubal ligation and male condom were respectively 31.8% (95%CI 28.4-35.3), 11.1% (95%CI 9.0-13.6) and 10.9% (95%CI 8.7-13.3). In addition, 10.5% (n = 77) of the women reported making combined use of oral contraceptive pills and condom. In the stratified analysis, younger women with lower education level and from lower social classes reported less use of oral contraceptive pills. Tubal ligation was more prevalent among the lower social classes, but only in the age group from 30 to 39 years old. No differences were found in relation to male condom. CONCLUSIONS: The results indicated that differences persist in relation to contraception, which can be associated with both the difficulties of access to these inputs and the frailty of actions in reproductive health to achieve the needs and preferences of women who are more socially vulnerable.

RESUMO OBJETIVO: Descrever os métodos contraceptivos utilizados e fatores demográficos e socioeconômicos associados em mulheres adultas. MÉTODOS: Estudo transversal de base populacional com mulheres de 20 a 49 anos de São Leopoldo, RS, em 2015. Foram considerados três desfechos para analisar a associação com características demográficas e socioeconômicas: uso de anticoncepcional oral, ligadura tubária e uso de preservativo masculino. Foram obtidas razões de prevalências, brutas e estratificadas por idade, e intervalos de confiança de 95% (IC95%) por meio de regressão de Poisson, levando em conta o erro de delineamento. RESULTADOS: Foram avaliadas 736 mulheres com idades entre 20 e 49 anos. A prevalência de uso de anticoncepcional oral, de ligadura tubária e de uso de preservativo masculino foram, respectivamente, 31,8% (IC95% 28,4-35,3), 11,1% (IC95% 9,0-13,6) e 10,9% (IC95% 8,7-13,3). Além disso, 10,5% (n = 77) das mulheres relataram fazer uso combinado de anticoncepcional oral e preservativo masculino. Na análise estratificada, as mulheres mais jovens, de menor escolaridade e classe econômica mais baixa relataram menor uso de anticoncepcional oral. Já a ligadura tubária foi mais prevalente entre as de classe econômica mais baixa, mas apenas na faixa etária de 30 a 39 anos. Não foram encontradas diferenças quanto ao preservativo masculino. CONCLUSÕES: Os resultados indicaram que ainda persistem diferenças quanto à contracepção, o que pode se relacionar tanto a dificuldades no acesso a esses insumos como a fragilidades das ações em saúde reprodutiva para atingir as necessidades e preferências das mulheres em maior vulnerabilidade social.

Barriers and outcomes associated with unfulfilled requests for permanent contraception following vaginal delivery.

OBJECTIVES: To identify barriers to postpartum permanent contraception procedures after vaginal delivery and to explore contraceptive and reproductive outcomes of women who experience unfulfilled requests. STUDY DESIGN: We performed a retrospective cohort study of women requesting postpartum permanent contraception after vaginal delivery from 7/1/11 to 6/30/14 at Strong Memorial Hospital in Rochester, NY. We ascertained patient characteristics and outcomes through electronic medical records and birth certificate data search. RESULTS: Of 189 women in our sample, 78 (41.3%) had a postpartum permanent contraception procedure. Factors associated with unfulfilled requests in adjusted analysis included BMI ≥40 (OR 3.71, 95% CI 1.46-9.48 compared to BMI <35), federal sterilization consent signed ≥36 weeks (OR 5.10, 95% CI 1.64-15.86 compared to <36 weeks) and delivery in the latter half of the week (Wednesday-Saturday) (OR 2.02, 95% CI 1.08-3.79). Documented reasons for unfulfilled permanent contraception requests included patient changing her mind related to procedural issues (21, 18.9%), invalid consent (20, 18.0%), maternal obesity (17, 15.3%), lack of operating room availability (14, 12.6%) and ambivalence about permanent contraception (5, 4.5%). Of 57 women who planned for interval permanent contraception and had institutional follow-up over the subsequent year, 14 (24.6%) had a procedure, 8 (14.0%) initiated long-acting reversible contraception, and 13 (22.8%) became pregnant. CONCLUSIONS: Fewer than half of women obtained desired postpartum permanent contraception after vaginal delivery, with logistical issues and obesity being the most common reported barriers. Health care providers should advocate for access to postpartum permanent contraception, as well as discuss prenatally the individualized probability of nonfulfillment and importance of alternative contraceptive plans. IMPLICATIONS: Logistical barriers and inappropriate antenatal preparation contribute to the fact that over half of women do not obtain desired postpartum permanent contraception after vaginal delivery. To respect reproductive autonomy and improve care, clinicians and other health officials should eliminate barriers to immediate postpartum permanent contraception while increasing access to alternative options.

Knowledge, attitudes, and perceptions of antenatal women to postpartum bilateral tubal ligation at Greys Hospital, KwaZulu-Natal, South Africa.

OBJECTIVES: To evaluate the associations between socio-demographic factors and the general knowledge, the attitudes and perceptions of women attending antenatal clinic at Greys Hospital regarding postpartum tubal ligation (BTL). METHODS: A prospective cross-sectional study describing the perceptions about BTL in 241 pregnant women was conducted. RESULTS: One hundred and sixty six (68.9%) participants needed to involve their partners before tubal ligation. Thirty five percent of 102 participants who would not have BTL against partner's wish were unemployed. Eighty three (34.4%) participants, mostly with secondary and tertiary education believed that successful reversal of BTL is guaranteed. Fifty two percent of participants, predominantly with no formal schooling and primary education levels were unaware of the risk of falling pregnant after BTL. Sixty seven (27.8%) participants, predominantly with primary education or no formal schooling believed that BTL protects against STIs and HIV. Seventy eight (32.4%) of participants would not have BTL due to religious beliefs, however, participants from the same religion gave different answers to the question. CONCLUSION: The study showed a significant lack of knowledge on key points of BTL. Socio-demographic factors still influence this subject and should not be underestimated during counselling of the patients to reduce potential morbidity and litigation.