The effect of tubal sterilization through electrocoagulation on the ovarian reserve

Background

The study was conducted to compare the effects of tubal sterilization through electrocoagulation and the application of mechanical clips on the ovarian reserve.

Study Design

Eighty-eight patients in the reproductive period with the desire of tubal sterilization were included in the prospective, randomized study. The patients were divided into two groups by simple randomization as tubal sterilization through electrocoagulation group and the application of mechanical clips group. Day-3 serum follicle stimulating hormone, luteinizing hormone, estradiol, inhibin-B and antimüllerian hormone and Day-3 total ovarian volume measurements and anthral follicle counts of all patients in the preoperative and 10th postoperative months were compared both within and between the two groups.

Results

A significant difference between the postoperative 10th-month Day-3 total ovarian volumes and anthral follicle counts was detected between the electrocoagulation and mechanical clips application groups.

Conclusion

Tubal sterilization by electrocoagulation is very likely to have an adverse effect on the ovarian reserve in the postoperative period.     

Prostate cancer and vasectomy: a hospital-based case-control study in China, Nepal and the Republic of Korea

Background

The study of a possible relationship between vasectomy and prostate cancer has yielded mixed results. Data from developing countries are limited.

Study Design

We conducted a hospital-based case-control study in China, Nepal and the Republic of Korea to evaluate the risk of prostate cancer after vasectomy.

Results

Prostate cancer in 294 cases (confirmed by independent pathologists) and 879 matched controls were included. The odds ratio of prostate cancer in men with a history of vasectomy was 1.21 [95% confidence interval (95% CI)=0.79, 1.87]. No significant trend was observed in risk by time since vasectomy or age at vasectomy. The odds ratio for localized disease was 1.02 (95% CI=0.53, 1.95); the odds ratio for later stages was 1.41 (95% CI=0.78, 2.53). No confounding factor was identified. The study illustrated differential misclassification of disease by vasectomy status; reference pathologists determined that 28% of men with a history of vasectomy, compared with 17% of men without a history of vasectomy, were misdiagnosed with prostate cancer by local pathologists.

Conclusion

Vasectomy is not associated with an increased risk of prostate cancer in developing countries where the rate of the disease is low.     

Potential unintended pregnancies averted and cost savings associated with a revised Medicaid sterilization policy

Objective

Medicaid sterilization policy, which includes a mandatory 30-day waiting period between consent and the sterilization procedure, poses significant logistical barriers for many women who desire publicly funded sterilization. Our goal was to estimate the number of unintended pregnancies and the associated costs resulting from unfulfilled sterilization requests due to Medicaid policy barriers.

Study Design

We constructed a cost-effectiveness model from the health care payer perspective to determine the incremental cost over a 1-year time horizon of the current Medicaid sterilization policy compared to a hypothetical, revised policy in which women who desire a postpartum sterilization would face significantly reduced barriers. Probability estimates for potential outcomes in the model were based on published sources; costs of Medicaid-funded sterilizations and Medicaid-covered births were based on data from the Medicaid Statistical Information System and The Guttmacher Institute, respectively.

Results

With the implementation of a revised Medicaid sterilization policy, we estimated that the number of fulfilled sterilization requests would increase by 45%, from 53.3% of all women having their sterilization requests fulfilled to 77.5%. Annually, this increase could potentially lead to over 29,000 unintended pregnancies averted and $215 million saved.

Conclusion

A revised Medicaid sterilization policy could potentially honor women’s reproductive decisions, reduce the number of unintended pregnancies and save a significant amount of public funds.

Implication

Compared to the current federal Medicaid sterilization policy, a hypothetical, revised policy that reduces logistical barriers for women who desire publicly funded, postpartum sterilization could potentially avert over 29,000 unintended pregnancies annually and therefore lead to cost savings of $215 million each year.     

The safety,efficacy and acceptability of task sharing tubal sterilization to midlevel providers: a systematic review

Background

Task sharing is an important strategy for increasing access to modern, effective contraception for women and reducing unmet need for family planning.

Objective

The objective was to identify evidence for the safety, efficacy or acceptability of task sharing tubal sterilization to midlevel providers.

Search strategy

We searched PubMed, Cochrane and Popline for articles in all languages using the following key words: task sharing, tubal sterilization, midlevel providers, task shifting.

Selection criteria

All studies reporting on any measure of safety, efficacy or acceptability of tubal sterilization performed by any cadre of midlevel providers.

Data collection and analysis

Data were independently abstracted by two authors and graded using the United States Preventive Services Task Force rating for evidence quality. Heterogeneity of outcome measures precluded a meta-analysis.

Main results

Nine studies of fair to poor quality reported on safety and acceptability outcomes. Generalizability of findings is limited by inadequate sample size and lack of statistical comparisons. No study reported on long-term efficacy outcomes.

Conclusions

Well-designed clinical trials, of adequate sample size, are urgently needed to establish the safety, efficacy and acceptability of task sharing tubal sterilization to midlevel providers.     

Contraceptive sterilization among married adults: national data on who chooses vasectomy and tubal sterilization

BackgroundVasectomy has been found to be a highly cost-effective contraceptive method. For couples, tubal sterilization and vasectomy have the same result, but the two methods are used by different segments of the population.Study designWe conducted an analysis of data from male and female samples of the 2006–2008 National Survey of Family Growth, nationally representative samples of men and women in the United States aged 15–44 years.ResultsAmong married men, 13.1% reported vasectomies (95% confidence interval 10.4%–16.3%), compared to 21.1% (17.8%–24.9%) of married women who reported tubal sterilizations. Men with higher education and income had greater prevalence of vasectomy than those less educated, while women with lower education and income had the highest prevalence of tubal sterilization.ConclusionsEfforts to promote vasectomy use need to understand the reasons behind these differences. Increasing the availability and use of vasectomy will require education about its benefits.     

An economic comparison of female sterilization of hysteroscopic tubal occlusion with laparoscopic bilateral tubal ligation

Background

This study compares the expected 5-year costs for permanent sterilization in women between nonincisional hysteroscopic tubal occlusion with the Essure® system performed in an office setting and laparoscopic bilateral tubal ligation (LBTL).

Study Design

An economic decision tree is used to predict outcomes and costs to compare these two procedures from a US Medicaid perspective over a 5-year time horizon.

Results

Expected costs are $2367 for Essure® and $3545 for LBTL (Essure® saves $1178 or 33% of LBTL costs). Sensitivity analyses show Essure® has lower expected costs across all values considered. If the cost for a LBTL procedure were to decrease by 20% and the cost for Essure® to increase by 20%, Essure® would have still have lower expected costs.

Conclusion

Office-based sterilization for women using Essure® can lead to substantial cost savings over 5 years compared to LBTL. This conclusion is robust to varying analytic inputs.     

Reconsidering racial/ethnic differences in sterilization in the United States

Objective

Cross-sectional studies have found that low-income and racial/ethnic minority women are more likely to use female sterilization and less likely to rely on a partner’s vasectomy than women with higher incomes and whites. However, studies of pregnant and postpartum women report that racial/ethnic minorities, particularly low-income minority women, face greater barriers in obtaining a sterilization than do whites and those with higher incomes. In this paper, we address this apparent contradiction by examining the likelihood a woman gets a sterilization following each delivery, which removes from the comparison any difference in the number of births she has experienced.

Study Design

Using the 2006–2010 National Survey of Family Growth, we fit multivariable-adjusted logistic and Cox regression models to estimate odds ratios and hazard ratios for getting a postpartum or interval sterilization, respectively, according to race/ethnicity and insurance status.

Results

Women’s chances of obtaining a sterilization varied by both race/ethnicity and insurance. Among women with Medicaid, whites were more likely to use female sterilization than African Americans and Latinas. Privately insured whites were more likely to rely on vasectomy than African Americans and Latinas, but among women with Medicaid-paid deliveries reliance on vasectomy was low for all racial/ethnic groups.

Conclusions

Low-income racial/ethnic minority women are less likely to undergo sterilization following delivery compared to low-income whites and privately insured women of similar parities. This could result from unique barriers to obtaining permanent contraception and could expose women to the risk of future unintended pregnancies.

Implications

Low-income minorities are less likely to undergo sterilization than low-income whites and privately insured minorities, which may result from barriers to obtaining permanent contraception, and exposes women to unintended pregnancies.     

Probability of pregnancy after sterilization: a comparison of hysteroscopic versus laparoscopic sterilization

Objective

To compare the expected probability of pregnancy after hysteroscopic versus laparoscopic sterilization based on available data using decision analysis.

Study design

We developed an evidence-based Markov model to estimate the probability of pregnancy over 10 years after three different female sterilization procedures: hysteroscopic, laparoscopic silicone rubber band application and laparoscopic bipolar coagulation. Parameter estimates for procedure success, probability of completing follow-up testing and risk of pregnancy after different sterilization procedures were obtained from published sources.

Results

In the base case analysis at all points in time after the sterilization procedure, the initial and cumulative risk of pregnancy after sterilization is higher in women opting for hysteroscopic than either laparoscopic band or bipolar sterilization. The expected pregnancy rates per 1000 women at 1 year are 57, 7 and 3 for hysteroscopic sterilization, laparoscopic silicone rubber band application and laparoscopic bipolar coagulation, respectively. At 10 years, the cumulative pregnancy rates per 1000 women are 96, 24 and 30, respectively. Sensitivity analyses suggest that the three procedures would have an equivalent pregnancy risk of approximately 80 per 1000 women at 10 years if the probability of successful laparoscopic (band or bipolar) sterilization drops below 90% and successful coil placement on first hysteroscopic attempt increases to 98% or if the probability of undergoing a hysterosalpingogram increases to 100%.

Conclusion

Based on available data, the expected population risk of pregnancy is higher after hysteroscopic than laparoscopic sterilization. Consistent with existing contraceptive classification, future characterization of hysteroscopic sterilization should distinguish “perfect” and “typical” use failure rates.

Implications

Pregnancy probability at 1 year and over 10 years is expected to be higher in women having hysteroscopic as compared to laparoscopic sterilization.     

Adherence to hysterosalpingogram appointments following hysteroscopic sterilization among low-income women

Background

The few studies on post-Essure hysterosalpingogram (HSG) adherence rates show inconsistent results. This study examined associations between sociodemographic variables not examined in prior studies and HSG adherence among low-income women.

Study Design

Medical records of 286 women who underwent sterilization between August 31, 2005, and September 30, 2011, were reviewed. chi-Square and Mann–Whitney U tests were used to determine variable associations with HSG adherence.

Results

The adherence rate for the first HSG was 85.0% (243/286). Variables associated with adherence were lower education level (p=.01), not working outside the home (p=.04), being married (p<.0001), lower gravidity (p=.03), fewer lifetime number of sexual partners (p<.0001), no sexually transmitted infection history (p<.01), Hispanic ethnicity (p<.0001), Spanish as a primary language (p<.0001) and living farther from the clinic (p<.01).

Conclusions

This study demonstrates that achieving high rates of adherence with the recommended HSG following Essure placement is feasible among low income populations. Furthermore, not speaking English or having to commute a far distance to the clinic do not appear to be barriers. This is encouraging considering the importance of this test to confirm tubal occlusion.     

Cost effectiveness of contraceptives in the United States

Background

The study was conducted to estimate the relative cost effectiveness of contraceptives in the United States from a payer's perspective.

Methods

A Markov model was constructed to simulate costs for 16 contraceptive methods and no method over a 5-year period. Failure rates, adverse event rates and resource utilization were derived from the literature. Sensitivity analyses were performed on costs and failure rates.

Results

Any contraceptive method is superior to “no method”. The three least expensive methods were the copper-T intrauterine device (IUD) (US$647), vasectomy (US$713) and levonorgestrel (LNG)-20 intrauterine system (IUS) (US$930). Results were sensitive to the cost of contraceptive methods, the cost of an unintended pregnancy and plan disenrollment rates.

Conclusion

The copper-T IUD, vasectomy and the LNG-20 IUS are the most cost-effective contraceptive methods available in the United States. Differences in method costs, the cost of an unintended pregnancy and time horizon are influential factors that determine the overall value of a contraceptive method.     

Cancer risk after sterilization with transcervical quinacrine: updated findings from a Chilean cohort

Background

Dating back to the 1970s, thousands of women worldwide have voluntarily been sterilized with transcervical insertion of quinacrine pellets. The safety and efficacy of the technology are still being assessed today; in particular, better estimates on the incidence of human cancers are now feasible.

Methods

We conducted a cohort study of 1492 women in Santiago and Valdivia, Chile, who received transcervical quinacrine pellets for contraceptive sterilization between l977 and l989. We periodically interviewed women with the last interviews in 2006-2007 and reviewed their medical records. We calculated age and site-specific incidence of invasive cancers and compared the observed cases to the number of expected cases based on data from the Cali, Colombia, cancer registry, gathered by the International Agency for Research on Cancer.

Results

During 23,894 person-years of follow-up, 41 invasive cancers were identified, including 16 new cases that had occurred since the previous analysis. Ten cases of cervical cancer were observed, compared with 12.1 expected. Since the initial study's confirmation of a single case of leiomyosarcoma, no other uterine cancers have been diagnosed. We would expect 2.0 uterine cancers during this number of observed women-years. One case of ovarian cancer was diagnosed, compared with 3.1 expected.

Conclusion

Rates of cancer among women exposed to intrauterine quinacrine are similar to population-based rates.     

Physicians' attitudes, recommendations and practice of male and female sterilization in S?o Paulo

While prevalence of vasectomy is low in Brazil, female sterilization is very high. The potential for growth of vasectomy services may be related to attitudes and practices of physicians. In 1984, 660 physicians at seven major hospitals in S?o Paulo were randomly selected from a total population of 2207 physicians in these hospitals. They were interviewed about their attitudes towards family planning in general, and specifically towards voluntary sterilization. A high degree of vasectomy among this medical community is indicated by its relatively high prevalence among married physicians and their spouses; about one in ten reported that either they or their spouse had had a vasectomy. Half of the physicians who perform sterilizations perform vasectomies: 22% of obstetricians and gynecologists, 85% of surgeons, and all urologists. In general, physicians would recommend vasectomy and tubal ligation equally often to their clients. Depending on the circumstances, up to 85% of all physicians recommend some sterilization procedure. Recommendation was modified by the type of procedure a physician performed, and by the patient's characteristics. Physician's recommendations of sterilization increased with age and parity of patient and was related to the health conditions and socioeconomic circumstances of the couple.     

Correlates of physical activity in Morocco

Purpose

To estimate the prevalence of physical activity (PA) and associated variables in the Moroccan adult population.

Methods

Population-based, May 2008 survey of a representative sample of Moroccan adults. PA was assessed using the International Physical Activity Questionnaire (IPAQ).

Results

Mean age was 41.4 years (26.2-56.6). Of the 2613 subjects, 48.1% were women and 58% lived in urban areas. The prevalence of the lowest physically active category was 16.5% overall, 24% in women and 9% in men (p < 0.001). Unemployed (18.6%) and retired individuals (17.9%), housewives (28.2%) and married persons (19.7%) reported lower levels of physical activity. Older age, unemployment or retirement, having high income, and being overweight or obese were the main determinants of low PA levels in men. In women, the main determinants of low PA levels were living in an urban area and being a housewife.

Conclusion

This survey has identified that urbanization and having high income are main determinants of low physical activity in Moroccan adults in a country undergoing economic transition.     

Will ethylene oxide sterilization influence the application of novel Cu/LDPE nanocomposite intrauterine devices?

Background

Copper/low-density polyethylene (Cu/LDPE) nanocomposite intrauterine device (IUD) is an implanted medicinal device that must be sterilized before use. Sterilization processes act either chemically or physically, leading to a lethal change in the structure or function of organic macromolecules in microorganisms. Given the nature of their action, sterilization might also attack the macromolecules of polymers by the same mechanisms, resulting in changes in surface functional groups and in the internal structure of the polymer. If sterilization leads to changes in surface functional groups and in the internal structure of the LDPE matrix, which will influence the mechanical property and cupric ions release rate of novel Cu/LDPE nanocomposite IUDs, potential clinical application will be limited. Therefore, it is necessary to study the influence of ethylene oxide sterilization on the potential clinical application of novel Cu/LDPE nanocomposite IUDs.

Study Design

The influence of ethylene oxide sterilization on the internal structure, surface functional groups, mechanical property and cupric ions release rate of novel Cu/LDPE nanocomposite IUDs was studied using differential scanning calorimetry, attenuated total reflection Fourier transform infrared spectroscopy, tensile testing and absorbance measurement.

Results

Ethylene oxide sterilization did not have any influence on the internal structure, surface functional groups, mechanical property and cupric ions release rate of novel Cu/LDPE nanocomposite intrauterine devices.

Conclusion

Ethylene oxide sterilization will not affect the potential application of novel Cu/LDPE nanocomposite IUDs.     

“We never thought of a vasectomy”: a qualitative study of men and women's counseling around sterilization

Background

Sterilization is the most commonly used method of contraception in the United States; however, little is known about how providers counsel about these procedures or the information patients desire. In this study, we explore male and female experiences of sterilization counseling and their perspectives on ideal sterilization counseling.

Study design

In-depth individual and group interviews were conducted with 37 heterosexual couples between the ages of 25 and 55 years. Each couple had reached their desired family size. Interviews were recorded and transcribed using NVivo software and analyzed using modified grounded theory.

Results

Men and women differed in their experiences of sterilization counseling. Women commonly received counseling on female sterilization but not vasectomy, while men rarely discussed either form of sterilization with their providers. Both men and women desired more information about sterilization.

Conclusions

Contraceptive counseling of couples who have completed childbearing does not routinely include men or the option of vasectomy, despite the advantages of this method with respect to safety, efficacy and cost. Family planning and primary care providers have an important role in ensuring that couples are aware of all their options and can make an informed decision about their contraception.     

Improving hysterosalpingogram confirmatory test follow-up after Essure hysteroscopic sterilization

Background

Given the need for a 90-day post-Essure hysterosalpingogram (HSG) to confirm proper tubal placement and occlusion, we examined the impact of dedicating a staff nurse to schedule HSG appointments, call with appointment reminders and track HSG compliance for patients who had Essure.

Study Design

We performed a retrospective chart review for patients who underwent Essure sterilization between October 2003 and January 2009. We compared rates of HSG compliance and confirmed tubal occlusion for patients before February 2008 with rates after the protocol change occurred.

Results

Seventy-eight percent of preintervention patients were compliant with at least one HSG following Essure placement compared to 90.9% in the post-intervention group (p value=.033). Tubal occlusion was confirmed by postprocedure HSGs for 123/173 patients (71.1%) in the preintervention group and 48/55 patients (87.3%) in the postintervention group. Patients followed by our staff after our protocol change were more likely to undergo post-Essure compliance (Odds ratio= 2.7, confidence interval = 1.2–7.1, p=.01).

Conclusion

Dedicating a staff nurse to track patients' HSG follow-up as a multicheck system resulted in an improvement in HSG compliance and rates of confirmed tubal placement and occlusion.     

Gastrointestinal Tolerance of Chicory Inulin Products

Background

The use of inulin in foods as a fiber source has increased recently. Consumption of inulin products can cause gastrointestinal (GI) distress. Acceptable intakes of inulin need to be determined.

Objective

To determine the GI tolerance of two inulin fibers, shorter chain length oligofructose and native inulin, at 5- and 10-g doses compared to a placebo.

Design

A randomized, double-blind, controlled, crossover design that included a phone screening and five visits for breakfast fiber challenges consisting of a bagel, cream cheese, and orange juice.

Subjects/setting

Twenty-six healthy men and women ages 18 to 60 years participated in the study. Healthy subjects with no history of GI conditions consumed diets with typical amounts of fiber.

Main outcome measures

GI tolerance was calculated as the sum of scores on seven GI tolerance domains via questionnaire administered at t=0, 2, 4, 24, and 48 hours following fiber challenge.

Statistical analyses performed

A mixed effects linear model was used to compare the tolerance scores among the five fiber challenges.

Results

The two inulin fibers tended to increase GI symptoms mildly. Most frequently reported symptoms were flatulence followed by bloating. The 10-g dose of oligofructose substantially increased GI symptoms compared to control.

Conclusions

Doses up to 10 g/day of native inulin and up to 5 g/day of oligofructose were well-tolerated in healthy, young adults.     

La auditoría energética: una herramienta de gestión en atención primaria

Objective

The aim of this study was to evaluate the viability of energy audit as a management tool in primary care to improve the energy efficiency and environmental performance of a health center by reducing its operating costs.

Method

We conducted 55 energy audits in health centers from 2005-2010. The health centers were sized between 500 and 3,500 m², were located in health areas with 3,500 to 25,000 users, and were built between 1985 and 2007.

Results

With an average investment of 11,601€ per site, energy consumption can be reduced by 10,801 kWh per year, saving 2,961€ with a mean payback period of 3.92 years, and preventing emission of 7,010 kg of CO₂.

Conclusions

Energy auditing is a practical tool to reduce the operating and maintenance costs of health centers and of improving the comfort of the facilities.