Long-term risk of ectopic pregnancy varies by method of tubal sterilization: a whole-population study

Efficacy of Tubal Surgery for Permanent Contraception: Considerations for the Clinician

Permanent contraception meets the needs of many people certain in their decision to never become pregnant in the future. Female permanent contraception procedures became more common than male procedures during the 1970s and 1980s, when laparoscopic surgery became widely available. To better understand the efficacy of these new procedures, the US Centers for Disease Control and Prevention conducted a prospective cohort study, known as the Collaborative Review of Sterilization (CREST). For decades, results of this study have defined perioperative counseling around failure risks of such surgeries. However, laparoscopic technology and techniques have changed significantly in recent decades and evidence has emerged supporting noncontraceptive benefits of tubal excision. Therefore, we present here a review of updated information regarding permanent contraception failure in the modern context and implications for clinical practice and future research directions.

Spontaneous Bilateral Ectopic Pregnancy Treated With Combination of Methotrexate, Unilateral Salpingectomy, and Unilateral Expulsion of Pregnancy

Spontaneous bilateral ectopic pregnancies are rare. In the majority of case reports, treatments prescribed were methotrexate, bilateral salpingectomy, or salpingectomy/salpingostomy. A 31-year-old gravida 3 para 0 at our institution underwent diagnostic laparoscopy due to ruptured ectopic pregnancy, and based on visual inspection, had a bilateral ectopic pregnancy. She underwent right salpingectomy for a ruptured ectopic pregnancy and had spontaneous expulsion of the left ectopic pregnancy with mobilization of the fallopian tube. She received methotrexate as per the two-dose protocol and was followed with a negative beta-human chorionic gonadotropin (b-hCG). Pathology confirmed bilateral tubal ectopic pregnancies. Spontaneous bilateral tubal ectopic pregnancy requires a high level of clinical suspicion. If a tubal pregnancy has expulsion of tissue intraoperatively, a two-dose protocol for methotrexate administration may be used for treatment, especially in the case of a bilateral ectopic pregnancy with fertility desires.

Comparing options for females seeking permanent contraception in high resource countries: a systematic review

BACKGROUND

Multiple options for permanent or long-acting contraception are available, each with adverse effects and benefits. People seeking to end their fertility, and their healthcare providers, need a comprehensive comparison of methods to support their decision-making. Permanent contraceptive methods should be compared with long-acting methods that have similar effectiveness and lower anticipated adverse effects, such as the levonorgestrel-releasing intrauterine contraception (LNG-IUC). We aimed to understand the comparability of options for people seeking to end their fertility, using high-quality studies. We sought studies comparing laparoscopic tubal ligation, hysteroscopic tubal occlusion, bilateral salpingectomy, and insertion of the LNG-IUC, for effectiveness, adverse events, tolerability, patient recovery, non-contraceptive benefits, and healthcare system costs among females in high resource countries seeking to permanently avoid conception.

METHODS

We followed PRISMA guidelines, searched EMBASE, Pubmed (Medline), Web of Science, and screened retrieved articles to identify additional studies. We extracted data on population, interventions, outcomes, follow-up, health system costs, and study funding source. We used the Newcastle-Ottawa Scale to assess risk of bias and excluded studies with medium-high risk of bias (NOS < 7). Due to considerable heterogeneity, we performed a narrative synthesis.

RESULTS

Our search identified 6,612 articles. RG, BV, BC independently reviewed titles and abstracts for relevance. We reviewed the full text of 154 studies, yielding 34 studies which met inclusion criteria. We excluded 10 studies with medium-high risk of bias, retaining 24 in our synthesis. Most studies compared hysteroscopic tubal occlusion and/or laparoscopic tubal ligation. Most comparisons reported on effectiveness and adverse events; fewer reported tolerability, patient recovery, non-contraceptive benefits, and/or healthcare system costs. No comparisons reported accessibility, eligibility, or follow-up required. We found inconclusive evidence comparing the effectiveness of hysteroscopic tubal occlusion to laparoscopic tubal ligation. All studies reported adverse events. All forms of tubal interruption reported a protective effect against cancers. Tolerability appeared greater among tubal ligation patients compared to hysteroscopic tubal occlusion patients. No high-quality studies included the LNG-IUC.

CONCLUSIONS

Studies are needed to directly compare surgical forms of permanent contraception, such as tubal ligation or removal, with alternative options, such as intrauterine contraception to support decision-making.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO [CRD42016038254].

Measuring complications of serious pediatric emergencies using ICD-10

OBJECTIVE

To create definitions for complications for 16 serious pediatric conditions using the International Classification of Diseases, 10th Revision, Clinical Modification or Procedure Coding System (ICD-10-CM/PCS), and to assess whether complication rates are similar to those measured with ICD-9-CM/PCS.

DATA SOURCES

The Healthcare Cost and Utilization Project State Emergency Department and Inpatient Databases from five states between 2014 and 2017 were used to identify cases and assess complication rates. Incidences were calculated using population counts from the 5-year American Community Survey.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified by the presence of a diagnosis code for one of the 16 serious conditions. Only the first encounter for a given condition by a patient was included. Encounters resulting in transfer were excluded as the presence of complications was unknown.

STUDY DESIGN

We defined complications using data elements routinely available in administrative databases including ICD-10-CM/PCS codes. The definitions were adapted from ICD-9-CM/PCS using general equivalence mappings and refined using consensus opinion. We included 16 serious conditions: appendicitis, bacterial meningitis, compartment syndrome, new-onset diabetic ketoacidosis (DKA), ectopic pregnancy, empyema, encephalitis, intussusception, mastoiditis, myocarditis, orbital cellulitis, ovarian torsion, sepsis, septic arthritis, stroke, and testicular torsion. Using data from children under 18 years, we compared incidences and complication rates across the ICD-10-CM/PCS transition for each condition using interrupted time series.

PRINCIPAL FINDINGS

There were 61 314 ED visits for a serious condition; the most common was appendicitis (n = 37 493). Incidence rates for each condition were not significantly different across the ICD-10-CM/PCS transition for 13/16 conditions. Three differed: empyema (increased 42%), orbital cellulitis (increased 60%), and sepsis (increased 26%). Complication rates were not significantly different for each condition across the ICD-10-CM/PCS transition, except appendicitis (odds ratio 0.62, 95% CI 0.57-0.68), DKA (OR 3.79, 95% CI 1.92-7.50), and orbital cellulitis (OR 0.53, 95% CI 0.30-0.95).

CONCLUSIONS

For most conditions, incidences and complication rates were similar before and after the transition to ICD-10-CM/PCS codes, suggesting our system identifies complications of conditions in administrative data similarly using ICD-9-CM/PCS and ICD-10-CM/PCS codes. This system may be applied to screen for cases with complications and in health services research.

Contribution of genetic polymorphism of methylene tetrahydrofolate reductase on the effect of methotrexate in ectopic pregnancy patients

Background

Methotrexate (MTX) is the prior drug in ectopic pregnancy (EP). However, approximately 10% of patients suffer from failure by MTX therapy. Reduced folate carrier 1 (RFC1), methylene tetrahydrofolate reductase (MTHFR), and dihydrofolate reductase (DHFR) are involved in the transport and effects of MTX in vivo. In the present study, we aim to investigate the relationship between the genetic polymorphisms of RFC1, MTHFR, and DHFR and the clinical efficacy of MTX in tubal pregnancies.

Methods

100 patients of EP were enrolled in this study. Polymorphisms of RFC1 G80A, MTHFR C677T, and DHFR A‐317G were genotyped. β‐hCG level was detected in day 0, 4, and 7 after MTX injection. Association of MTX efficacy and genetic polymorphisms was analyzed.

Results

Methylene tetrahydrofolate reductase C677T was associated with MTX treatment (P = .017). The success rate of first MTX injection was superior in patients with harboring mutation allele of MTHFR gene than that in patients with wild‐type gene (P = .001). However, there was no significant association between the polymorphisms of RFC1 G80A, DHFR A‐317G, and surgical treatment (P = .709 and .476, respectively). In addition, β‐hCG level decrement was not significantly changed by MTX injection with different polymorphisms of RFC1, MTHFR, and DHFR on either day 4 (P = .214, 0.197 and 0.270, respectively) or day 7 (P = .172, .554, and .726, respectively).

Conclusion

Our results suggested that the reliable indicator was polymorphism of MTHFR C677T in failure by MTX injection.

Contraception after pregnancy

Whatever the outcome, pregnancy provides the opportunity to offer effective contraception to couples motivated to avoid another pregnancy. This narrative review summarizes the evidence for health providers, drawing attention to current guidelines on which contraceptive methods can be used, and when they should be started after pregnancy, whatever its outcome. Fertility returns within 1 month of the end of pregnancy unless breastfeeding occurs. Breastfeeding, which itself suppresses fertility after childbirth, influences both when contraception should start and what methods can be used. Without breastfeeding, effective contraception should be started as soon as possible if another pregnancy is to be avoided. Interpregnancy intervals of at least 6 months after miscarriage and 1-2 years after childbirth have long been recommended by the World Health Organization in order to reduce the chance of adverse pregnancy outcome. Recent research suggests that this may not be necessary, at least for healthy women <35 years old. Most contraceptive methods can be used after pregnancy regardless of the outcome. Because of an increased risk of venous thromboembolism associated with estrogen-containing contraceptives, initiation of these methods should be delayed until 6 weeks after childbirth. More research is required to settle the questions over the use of combined hormonal contraception during breastfeeding, the use of injectable progestin-only contraceptives before 6 weeks after childbirth, and the use of both hormonal and intrauterine contraception after gestational trophoblastic disease. The potential impact on the risk of ectopic pregnancy of certain contraceptive methods often confuses healthcare providers. The challenges involved in providing effective, seamless service provision of contraception after pregnancy are numerous, even in industrialized countries. Nevertheless, the clear benefits demonstrate that it is worth the effort.

Demographic, lifestyle, and reproductive risk factors for ectopic pregnancy

OBJECTIVE

To evaluate the relationship between demographic, lifestyle, and reproductive factors and the risk of ectopic pregnancy (EP).

DESIGN

Prospective cohort.

SETTING

United States.

PATIENT(S)

Nurses' Health Study II cohort comprising 41,440 pregnancies from 22,356 women.

INTERVENTION(S)

Demographic, lifestyle, and reproductive factors self-reported in 1989 then updated every 2 years. Multivariable log-binomial regression models with generalized estimating equations were used to estimate adjusted risk ratios (aRR).

MAIN OUTCOME MEASURE(S)

Ectopic pregnancy.

RESULT(S)

Incident EP was reported in 411 (1.0%) pregnancies. Former and current smokers had 1.22 (95% confidence interval [CI], 0.97-1.55) and 1.73 (95% CI, 1.28-2.32) times, respectively, the risk of EP compared with never smokers. The risk of EP 10 years after quitting was similar to never smokers (aRR 0.90; 95% CI, 0.60-1.33). Women consuming ≥10 g/day of alcohol had 1.50 (95% CI, 1.08-2.09) times the risk of EP compared with never consumers. In utero exposure to diethylstilbestrol (aRR 3.55; 95% CI, 2.51-5.01), earlier initiation of oral contraceptives (aRR 2.64; 95% CI, 1.70-4.09 for <16 years vs. never), intrauterine device use (aRR 3.99; 95% CI, 2.06-7.72), or history of infertility (aRR 3.03; 95% CI, 2.48-3.71) or tubal ligation (aRR 16.27; 95% CI, 11.76-22.53) also were associated with a higher risk of EP.

CONCLUSION(S)

Women who were current or former smokers, consumed ≥10 g/day of alcohol, were exposed to diethylstilbestrol in utero, initiated oral contraceptives at earlier than age 16 years (which may be a marker of riskier sexual behaviors), and who had a history of infertility, intrauterine device use, or tubal ligation had a higher risk of EP.

The Diagnosis and Treatment of Ectopic Pregnancy

BACKGROUND

Extrauterine pregnancy is a complication of the first trimester of pregnancy that arises in 1.3-2.4% of all pregnancies.

METHODS

This review is based on articles and guidelines retrieved by a selective PubMed search.

RESULTS

The presentation of extrauterine pregnancy is highly variable, ranging from an asymptomatic state, to pelvic pain that is worse on one side, to tubal rupture with hemorrhagic shock. 75% of tubal pre gnancies can be detected by transvaginal ultrasonography. In patients with a vital extrauterine pregnancy, the human chorionic gonadotropin concentration generally doubles within 48 hours. Laparoscopy is the gold standard of treatment. Two randomized, controlled trials comparing organ-preserving treatment with ablative surgery revealed no significant difference in pregnancy rates after the intervention, but precise details of the surgical procedures were not provided, and long-term fertility data are lacking. Metho - trexate therapy should be used only for strict indications.

CONCLUSION

Further randomized, controlled trials with longer follow-up will be needed to answer currently open questions about the potential for individualized surgical treatment and the proper role of pharmacotherapy.

Transcervical administration of polidocanol foam prevents pregnancy in female baboons

Background

Our objective was to conduct a pilot study to determine if transcervical administration of polidocanol foam (PF) with or without doxycycline or benzalkonium chloride (BZK) would prevent pregnancy in baboons.

Methods

In study phase 1, adult cycling baboons underwent a hysterosalpingogram to evaluate tubal patency prior to transcervical infusion of 20 mL of 5% PF followed by 1 mL of saline containing 100 mg doxycycline (5%/doxy; n=5), 3% PF plus doxycycline (3%/doxy; n=4), 3% PF with 0.01% BZK (3%/BZK; n=4) or no additional treatment (control; n=9). Immediately following treatment, animals received intramuscular depot medroxyprogesterone acetate (DMPA, 2 mg/kg) to suppress cyclicity during healing and were then socially housed with males of proven fertility. The primary outcome was pregnancy within six cycles of resumption of menses (efficacy phase 1). During study phase 2, PF-treated females from study phase 1 contributed additional cycles (6–8) of exposure (efficacy phase 2), and 5 control females who had recovered from medical abortion (after study phase 1 pregnancy) were subsequently treated with 5% PF (with DMPA) and exposed to breeding (efficacy phase 1; n=3 six cycles, n=2 five cycles).

Results

All females resumed normal menstrual cycles and mating activity after DMPA. During efficacy phase 1, 7/9 (78%) control females became pregnant. In contrast, fewer pregnancies occurred in PF-treated females: 5% PF 0/5 (0%), 5%/doxy 1/5 (20%), 3%/doxy 1/4 (25%) and 3%/BZK 1/4 (25%). During efficacy phase 2, only one additional pregnancy occurred (3%/BZK).

Conclusions

A single transcervical treatment with 5% PF prevented pregnancy in most baboons. Cotreatment with doxycycline or BZK did not improve results.

Implications

Transcervical intrauterine administration of PF resulted in a high rate of tubal occlusion with prevention of pregnancy; refinements are needed to increase the contraceptive rate following a single treatment to near 100%.

Update on permanent contraception options for women

PURPOSE OF REVIEW

Permanent methods are the most commonly used contraceptive options worldwide. Even with the increase in popularity and accessibility of long-acting reversible methods, there remains high demand for permanent options, especially among women in developing countries.

RECENT FINDINGS

Traditional methods of permanent contraception, such as postpartum tubal ligation and interval surgical tubal occlusion or electrocautery by mini-laparotomy or laparoscopy are well tolerated and highly effective. Bilateral total salpingectomy for ovarian cancer risk reduction is currently being investigated. Hysteroscopic tubal occlusion reduces or eliminates the need for anesthesia, but requires surgical training and specialized equipment. Alternative permanent contraception methods are being explored including immediately effective hysteroscopic methods, and nonsurgical permanent contraception methods that have the potential to improve access and reduce cost.

SUMMARY

Permanent contraception methods are an important part of the contraceptive methods mix designed to meet the needs of women who have completed desired family size or wish never to become pregnant. Current surgical approaches to permanent contraception are well tolerated and highly effective. The development of a highly effective nonsurgical approach could simplify the provision of permanent contraception.

What's more general than a whole population?

Statistical inference is commonly said to be inapplicable to complete population studies, such as censuses, due to the absence of sampling variability. Nevertheless, in recent years, studies of whole populations, e.g., all cases of a certain cancer in a given country, have become more common, and often report p values and confidence intervals regardless of such concerns. With reference to the social science literature, the current paper explores the circumstances under which statistical inference can be meaningful for such studies. It concludes that its use implicitly requires a target population which is wider than the whole population studied - for example future cases, or a supranational geographic region - and that the validity of such statistical analysis depends on the generalizability of the whole to the target population.

Live delivery outcome after tubal sterilization reversal: a population-based study

OBJECTIVE

To determine the cumulative incidence of live delivery in women who underwent reversal of tubal sterilization.

DESIGN

Population-based retrospective cohort study.

SETTING

Hospitals in Western Australia.

PATIENT(S)

All women aged 20-44 years, with a history of hospital admission for tubal sterilization, who subsequently underwent reversal of sterilization during the period 1985 to 2009 in Western Australia (n = 1,898).

INTERVENTION(S)

Data regarding reversal of sterilization and prior tubal sterilization were extracted from routinely collected administrative hospital separation records, until commencement of IVF treatment.

MAIN OUTCOME MEASURE(S)

First live-delivery rates.

RESULT(S)

There were 969 first live deliveries observed during the study period. The overall cumulative live-delivery rate was 20% (95% confidence interval [CI] 18-23) within the first year after reversal, 40% (95% CI 38-42) at 2 years, 51% (95% CI 48-53) at 5 years, and 52% (95% CI 50-55) at 10 years. The 5-year cumulative live-delivery rate was significantly lower in women who were aged 40-44 years (26%) compared with younger women (aged 20-29, 30-34, and 35-39 years) (50%, 56%, and 51%, respectively).

CONCLUSION(S)

Women undergoing reversal of sterilization before they reach age 40 years have at least a 50% chance of delivering a live baby within the next 5 years. Up to that age, there is no significant difference in live deliveries. The live-delivery rate halves after the age of 40 years.

Contraceptive Use and the Risk of Ectopic Pregnancy: A Multi-Center Case-Control Study

Objective

To evaluate the association between the risk of ectopic pregnancy (EP) and the use of common contraceptives during the previous and current conception/menstrual cycle.

Methods

A multi-center case-control study was conducted in Shanghai. Women diagnosed with EP were recruited as the case group (n = 2,411). Women with intrauterine pregnancy (IUP) (n = 2,416) and non-pregnant women (n = 2,419) were matched as controls at a ratio of 1∶1. Information regarding the previous and current use of contraceptives was collected. Multivariate logistic regression analyses were performed to calculate odds ratios (ORs) and the corresponding 95% confidential intervals (CIs).

Results

Previous use of intrauterine devices (IUDs) was associated with a slight risk of ectopic pregnancy (AOR₁ = 1.87 [95% CI: 1.48–2.37]; AOR₂ = 1.84 [1.49–2.27]), and the risk increased with the duration of previous use (P₁ for trend <10⁻⁴, P₂ for trend <10⁻⁴). The current use of most contraceptives reduced the risk of both unwanted IUP (condom: AOR = 0.04 [0.03–0.05]; withdrawal method: AOR = 0.10 [0.07–0.13]; calendar rhythm method: AOR = 0.54 [0.40–0.73]; oral contraceptive pills [OCPs]: AOR = 0.03 [0.02–0.08]; levonorgestrel emergency contraception [LNG-EC]: AOR = 0.22 [0.16–0.30]; IUDs: AOR = 0.01 [0.005–0.012]; tubal sterilization: AOR = 0.01 [0.001–0.022]) and unwanted EP (condom: AOR₁ = 0.05 [0.04–0.06]; withdrawal method: AOR₁ = 0.13 [0.09–0.19]; calendar rhythm method: AOR₁ = 0.66 [0.48–0.91]; OCPs: AOR₁ = 0.14 [0.07–0.26]; IUDs: AOR₁ = 0.17 [0.13–0.22]; tubal sterilization: AOR₁ = 0.04 [0.02–0.08]). However, when contraception failed and pregnancy occurred, current use of OCPs (AOR₂ = 4.06 [1.64–10.07]), LNG-EC (AOR₂ = 4.87 [3.88–6.10]), IUDs (AOR₂ = 21.08 [13.44–33.07]), and tubal sterilization (AOR₂ = 7.68 [1.69–34.80]) increased the risk of EP compared with the non-use of contraceptives.

Conclusion

Current use of most contraceptives reduce the risk of both IUP and EP. However, if the contraceptive method fails, the proportions of EP may be higher than those of non-users. In the case of contraceptive failure in the current cycle, EP cases should be differentiated according to current use of OCPs, LNG-EC, IUDs, and tubal sterilization. In addition, attention should be paid to women with previous long-term use of IUDs.