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There is increasing adoption of opportunistic salpingectomy for ovarian cancer prevention at the time of gynecologic surgery, which includes the postpartum period. However, there is no consensus on an ideal surgical approach for the parturient vasculature. We describe a safe, low-cost, and accessible approach for bilateral salpingectomy during cesarean delivery that we call the "Mesosalpinx Isolation Salpingectomy Technique" (MIST) that can guide institutions to standardize their postpartum salpingectomy procedures when advanced vessel-sealing devices are not available. In the MIST technique, avascular windows are created within the mesosalpinx close to the tubal vessels. The vasculature is thus fully skeletonized and isolated from the adjacent mesosalpinx before suture ligation, which ensures security of the free-tie to the individual vessels and avoids sharp injury to the mesosalpinx. Not using vessel-sealing devices also eliminates the risk of thermal injury to the adjacent ovarian tissue and vasculature and potentially achieves a cost-savings for the hospital and patient. MIST has been performed in 141 cesarean deliveries in the past 4 years. There were no noted bleeding complications during the salpingectomy procedure, blood transfusions, or instances of postoperative surgical reexploration. In our experience, a surgeon who is new to the procedure takes approximately 15 minutes to complete a bilateral salpingectomy. Those surgeons who are experienced in MIST need only 5 minutes. A video is included that demonstrates the technique., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Large scale public investment in family welfare programme has made female sterilization a free service in public health centers in India. Besides, it also provides financial compensation to acceptors. Despite these interventions, the use of contraception from private health centers has increased over time, across states and socio-economic groups in India. Though many studies have examined trends, patterns, and determinants of female sterilization services, studies on out-of-pocket payment (OOP) and compensations on sterilisation are limited in India. This paper examines the trends and variations in out-of-pocket payment (OOP) and compensations associated with female sterilization in India., Methods: Data from the National Family Health Survey - 4, 2015-16 was used for the analyses. A composite variable based on compensation received and amount paid by users was computed and categorized into four distinct groups. Multivariate analyses were used to understand the significant predictors of OOP of female sterilization., Results: Public health centers continued to be the major providers of female sterilization services; nearly 77.8% had availed themselves of free sterilization and 61.6% had received compensation for female sterilization. About two-fifths of the women in the economically well-off state like Kerala and one-third of the women in a poor state like Bihar had paid but did not receive any compensation for female sterilization. The OOP on female sterilization varies from 70 to 79% across India. The OOP on female sterilization was significantly higher among the educated and women belonging to the higher wealth quintile linking OOP to ability to pay for better quality of care., Conclusion: Public sector investment in family planning is required to provide free or subsidized provision of family welfare services, especially to women from a poor household. Improving the quality of female sterilization services in public health centers and rationalizing the compensation may extend the reach of family planning services in India.

Background: Removal of the fallopian tubes at the time of hysterectomy or interval sterilization has become routine practice to prevent ovarian cancer. While emerging as a strategy, uptake of this procedure at the time of cesarean delivery for pregnant women seeking permanent sterilization has not been widely adopted due to perceptions of increased morbidity and operative difficulty with a lack of available data in this setting., Objective: We sought to conduct a cost-effectiveness analysis comparing strategies for long-term sterilization and ovarian cancer risk reduction at the time of cesarean delivery, including bilateral tubal ligation, opportunistic salpingectomy, and long-acting reversible contraception., Study Design: A decision-analytic and cost-effectiveness model was constructed for pregnant women undergoing cesarean delivery who desired permanent sterilization in the US population, comparing 3 strategies: (1) bilateral tubal ligation, (2) bilateral opportunistic salpingectomy, and (3) postpartum long-acting reversible contraception. This theoretic cohort consisted of 110,000 pregnant women desiring permanent sterilization at the time of cesarean delivery and ovarian cancer prevention at an average of 35 years who were monitored for an additional 40 years based on an average US female life expectancy of 75 years. The primary outcome measure was the incremental cost-effectiveness ratio. Effectiveness was measured as quality-adjusted life years. Secondary outcomes included: the number of ovarian cancer cases and deaths, procedure-related complications, and unintended and ectopic pregnancies. The 1-, 2-, and 3-way and Monte Carlo probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set at $100,000., Results: Both bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery have favorable cost-effectiveness ratios. In the base case analysis, salpingectomy was more cost-effective with an incremental cost-effectiveness ratio of $23,189 per quality-adjusted life year compared to tubal ligation. Long-acting reversible contraception after cesarean was not cost-effective (ie, dominated). Although salpingectomy and tubal ligation were both cost-effective over a wide range of cost and risk estimates, the incremental cost-effectiveness ratio analysis was highly sensitive to the uncertainty around the estimates of salpingectomy cancer risk reduction, risk of perioperative complications, and cost. Monte Carlo probabilistic sensitivity analysis estimated that tubal ligation had a 49% chance of being the preferred strategy over salpingectomy. If the true salpingectomy risk of perioperative complications is >2% higher than tubal ligation or if the cancer risk reduction of salpingectomy is <52%, then tubal ligation is the preferred, more cost-effective strategy., Conclusion: Bilateral tubal ligation and bilateral opportunistic salpingectomy with cesarean delivery are both cost-effective strategies for permanent sterilization and ovarian cancer risk reduction. Although salpingectomy and tubal ligation are both reasonable strategies for cesarean patients seeking permanent sterilization and cancer risk reduction, threshold analyses indicate that the risks and benefits of salpingectomy with cesarean delivery need to be better defined before a preferred strategy can be determined., (Copyright © 2018. Published by Elsevier Inc.)

Objective: We sought to assess fulfillment of sterilization requests while accounting for the complex interplay between insurance, clinical and social factors in a contemporary context that included both inpatient and outpatient postpartum sterilization procedures., Study Design: This is a retrospective single-center cohort chart review study of 1331 women with a documented contraceptive plan at time of postpartum discharge of sterilization. We compared sterilization fulfillment within 90days of delivery, time to sterilization and rate of subsequent pregnancy after nonfulfillment between women with Medicaid and women with private insurance., Results: A total of 475 of 1030 Medicaid-insured and 100 of 154 privately insured women received postpartum sterilization (46.1% vs. 64.9%, p<.001). Women with Medicaid had a longer time from delivery to completion of the sterilization request (p<.001). After adjusting for age, parity, gestational age, mode of delivery, adequacy of prenatal care, race/ethnicity, marital status and education level, private insurance status was not associated with either sterilization fulfillment [odds ratio 0.94, 95% confidence interval (CI) 0.54-1.64] or time to sterilization (hazard ratio 1.03, 95% C.I. 0.73-1.34). Of the 555 Medicaid-insured women who did not receive a postpartum sterilization, 267 (48.1%) had valid Title XIX sterilization consent forms at time of delivery. Of women who did not receive sterilization, 132 of 555 Medicaid patients and 5 of 54 privately insured patients became pregnant within 1 year (23.8% vs. 9.3%, p=.023)., Conclusion: Differences in fulfillment rates of postpartum sterilization and time to sterilization between women with Medicaid versus private insurance are similar after adjusting for relevant clinical and demographic factors. Women with Medicaid are more likely than women with private insurance to have a short interval repeat pregnancy after an unfulfilled sterilization request., Implications: Efforts are needed to ensure that Medicaid recipients who desire sterilization receive timely services., (Copyright © 2018. Published by Elsevier Inc.)

Bill 20, An Act to Enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation, was introduced to reduce costs associated with Québec's healthcare in general and in vitro fertilisation (IVF) in particular. Passed in November 2015, the new law introduces a number of exclusion criteria for access to and funding for IVF treatment. Remarkably, one exclusion criterion-prior voluntary sterilisation-has prompted little critical commentary. The two justifications offered for restricting funding for IVF on the basis of voluntary sterilisation are that (1) there are cheaper options than IVF for sterilised individuals who want children, and (2) society should not have to pay for IVF for persons who are infertile by choice. I argue that both of these justifications are unsatisfactory, insofar as they contravene the chief value underlying, and current practices of, Canadian healthcare, and rely on problematic ascriptions of personal responsibility for health., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: Since the law of 4 July 2001, vasectomy has been recognized as a method of male contraception. We report the experience of vasectomy practice in a hospital-university center., Methods: A monocentric retrospective cohort study of 45 patients who benefited from a contraceptive vasectomy between July 2001 and May 2016. For each patient were studied: modalities of implementation, compliance with the recommendations of the 2001 law, costs and benefits generated by the intervention, the effectiveness of the gesture on the control spermograms, the satisfaction of the patients by a telephone questionnaire., Results: The mean age was 41.3 years. The second consultation was carried out in 91 % of the cases but the reflection period was not respected in 24 % of the cases. Written consent was signed in 89 % of cases. Vasectomy was performed on an outpatient basis in 73 % of cases, under local anaesthesia in 6.7 % of cases. The average cost per patient was 660.63 euros for an average gain of 524.50 euros, a loss of 136.13 euros. On the control spermogram, 54.3 % were azoosperms but the 3-month delay was not observed in 23 % of them. No patients expressed regret after surgery., Conclusion: The recommendations of the 2001 law were not systematically followed. This lack of standardization of practices, potential reflection of a lack of interest, is to be highlighted with the extra cost generated. The revaluation of the act should be integrated into the reflection of improvement of male sterilization practices., Level of Proof: 4., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

OBJECTIVE To determine characteristics of cats sterilized through a subsidized, reduced-cost spay-neuter program in Massachusetts and of owners who had their cats sterilized through this program. DESIGN Cross-sectional anonymous survey and telephone interviews. SAMPLE 1,188 (anonymous surveys) and 99 (telephone interviews) cat owners. PROCEDURES Owners who had a cat sterilized at clinics held between January 2006 and December 2008 were invited to complete anonymous surveys. Semistructured telephone interviews were conducted with owners who had a cat sterilized during clinics held in 2009. RESULTS Most cats had never been seen by a veterinarian previously; "too expensive" was the most common reason for this. Total annual household income was significantly associated with the number of times the cat had been examined by a veterinarian and reason why the cat had not been spayed or neutered previously. Most cats were acquired through informal means and without actively being sought, and there was often a time lag between acquisition and sterilization. Undesirable behavior and avoiding pregnancy were primary motivations for neutering and spaying, respectively. Nearly half of owners who indicated they would have had their cat sterilized through a private veterinarian if the clinic had not been available stated that the surgery would have been delayed because of cost. CONCLUSIONS AND CLINICAL RELEVANCE Findings suggested that spay-neuter decisions were related to owner income and procedure cost, that elimination of the reduced-cost spay-neuter program would likely have exacerbated the spay-delay problem, and that gradations of financial need should be considered when evaluating relationships between income and spay-neuter decisions.