Long-term Outcomes After Elective Sterilization Procedures—A Comparative Retrospective Cohort Study of Medicaid Patients

Abstract

The objectives were to compare the long-term outcomes, including hysterectomy, chronic pelvic pain (CPP) and abnormal uterine bleeding (AUB), in women post hysteroscopic sterilization (HS) and laparoscopic tubal ligation (TL) in the Medicaid population. Study design: This was a retrospective observational cohort analysis using data from the US Medicaid Analytic Extracts Encounters database. Women aged 18 to 49 years with at least one claim for HS (=3929) or TL (= n n 10,875) between July 1, 2009, through December 31, 2010, were included. Main outcome measures were hysterectomy, CPP or AUB in the 24 months poststerilization. Propensity score matching was used to control for patient demographics and baseline characteristics. Logistic regression analysis investigated the variables associated with a 24-month rate of each outcome in the HS versus laparoscopic TL cohorts. Results: Postmatching analyses were performed at 6, 12 and 24 months post index procedure. At 24 months, hysterectomy was more common in the laparoscopic TL than the HS group (3.5% vs. 2.1%; p=.0023), as was diagnosis of CPP (26.8% vs. 23.5%; p=.0050). No significant differences in AUB diagnoses were observed. Logistic regression identi ed HS as being associated with lower risk of hysterectomy (odds ratio [OR] 0.77 [95% fi confidence interval {CI} 0.60-0.97]; p=.0274) and lower risk of CPP diagnosis (OR 0.91 [95% CI 0.83-0.99]; p= .0336) at 24 months poststerilization. Conclusion: In Medicaid patients, HS is associated with a significantly lower risk of hysterectomy or CPP diagnosis 24 months poststerilization versus laparoscopic TL. Incidence of AUB poststerilization is not significantly different. While some differences in outcomes were statistically signi cant, the effect sizes were small, and the fi conclusion is one of equivalence and not clinical superiority. Implications statement: This propensity score matching analysis confirms that pelvic pain and AUB are common in women before and after sterilization regardless of whether the procedure is performed hysteroscopically or laparoscopically. Moreover, HS is associated with a signi cantly lower risk of hysterectomy or a CPP diagnosis fi in the 24 months poststerilization when compared to TL.

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

“…The characteristics and results of all included studies can be found in Table 1. Six studies compared effectiveness [34][35][36][37][38][39]; 15 assessed adverse effects [17,18,34,35,[38][39][40][41][42][43][44][45][46][47][48]; three compared patient recovery [18,35,44]; five compared non-contraceptive benefits, primarily the reduction of cancer risk [43,[49][50][51][52]; six compared tolerability [34,35,[37][38][39]52]; four compared costs to the healthcare system; [38,[53][54][55] and seven compared length of procedures [17,18,38,44,47,48,55]. No included studies compared accessibility, eligibility, or follow-up required.…”

Comparing Female Permanent Contraception Options in High Resource Countries: A Systematic Review

“…The characteristics and results of all included studies can be found in Table 1. Of the studies included for the narrative synthesis, six compared effectiveness; [24][25][26][27][28][29] sixteen assessed adverse effects; 11,24,25,[28][29][30][31][32][33][34][35][36][37][38][39][40] three compared patient recovery; 25,35,36 ve compared non-contraceptive bene ts, primarily the reduction of cancer risk; 34, 41-44 six compared tolerability; 24,25,[27][28][29]44 four compared costs to the healthcare system; 28,[45][46][47] and six compared length of procedures. 11,28,35,36,40,47 No included studies compared accessibility, eligibility, or follow-up required.…”

“…Sixteen studies assessed adverse effects using prospective/retrospective cohort designs. Results are organized by intervention: six compared hysteroscopic tubal occlusion and laparoscopic tubal ligation, 24,25,[28][29][30][31] three compared laparoscopic tubal ligation and a control, [32][33][34] ve compared laparoscopic tubal ligation and bilateral salpingectomy, 11,[35][36][37]40 one compared hysteroscopic tubal occlusion, laparoscopic tubal ligation with controls, and bilateral salpingectomy with controls, 38 and one compared bilateral salpingectomy with laparoscopic tubal ligation and with matched controls. 39 Hysteroscopic tubal occlusion vs. Laparoscopic tubal ligationTwo studies 24,30 found no statistically signi cant difference in rates of adverse effects including abnormal uterine bleeding, pelvic pain, or opioid managed pain between the two interventions.…”

“…One study found no difference between chronic pelvic pain, risk of hysterectomy, or abnormal uterine bleeding at 6 or 12 months post-procedure among women who underwent hysteroscopic tubal occlusion compared to laparoscopic tubal ligation, nding only a signi cantly lower risk of chronic pelvic pain and risk of hysterectomy among women undergoing hysteroscopic tubal occlusion at 24 months post-procedure. 31 Hysteroscopic tubal occlusion was associated with a lower risk of surgical complications than laparoscopic tubal ligation [aOR = 0.18 (0.14-0.23)] 25 and a lower risk of iatrogenic complications after surgery [OR = 0.35 (0.20, 0.61)]. 28 Two analyses found higher rates of gynecological complications with hysteroscopic tubal occlusion compared to laparoscopic tubal ligation, 25,29 with one analysis nding that menstrual dysfunction was signi cantly higher for people undergoing hysteroscopic tubal occlusion [aHR = 1.23 (1.20-1.27)].…”

“…Notably no studies comparing pain included patients selecting the LNG-IUC. One study found that hysteroscopic tubal occlusion patients had a lower risk of post-procedure hysterectomy 24-months post-procedure, 31 but the strength of the evidence is diminished with potential bias in funding from Bayer, the company that created the Essure™ device. Multiple studies have found an association between an increased risk of anal cancer and a history of laparoscopic tubal ligation.…”