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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.

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.)

Objectives: Opportunistic salpingectomy is a cost-effective strategy recommended for ovarian cancer (OvCa) risk reduction at the time of gynecologic surgery in women who have completed childbearing. We aimed to evaluate the cost-effectiveness of opportunistic salpingectomy compared to standard tubal ligation (TL) during cesarean delivery., Study Design: A cost-effectiveness analysis using decision modeling to compare opportunistic salpingectomy to TL at the time of cesarean using probabilities of procedure completion derived from a trial. Probability and cost inputs were derived from local data and the literature. The primary outcome was the incremental cost-effectiveness ratio (ICER) in 2017 U.S. dollars per quality-adjusted life year (QALY) at a cost-effectiveness threshold of $100,000/QALY. One- and two-way sensitivity analyses were performed for all variables. A probabilistic sensitivity analysis determined the proportion of simulations in which each strategy would be cost-effective., Results: Opportunistic salpingectomy was cost-effective compared to TL with an ICER of $26,616 per QALY. In 10,000 women desiring sterilization with cesarean, opportunistic salpingectomy would result in 17 fewer OvCa diagnoses, 13 fewer OvCa deaths, and 25 fewer unintended pregnancies compared to TL - with an associated cost increase of $4.7 million. The model was sensitive only to OvCa risk reduction from salpingectomy and TL. Opportunistic salpingectomy was not cost-effective if its cost was >$3163.74 more than TL, if the risk-reduction of salpingectomy was <41%, or if the risk-reduction of TL was >46%. In probabilistic sensitivity analysis opportunistic salpingectomy was cost effective in 75% of simulations., Conclusions: In women undergoing cesarean with sterilization, opportunistic salpingectomy is likely cost-effective and may be cost-saving in comparison to TL for OvCa risk reduction., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: Ovarian cancer is the most lethal gynaecologic cancer. Disease prevention may be the only method to reduce the incidence of ovarian cancer. The Society of Gynecologic Oncology advised that salpingectomies may be an appropriate and feasible strategy for ovarian cancer risk reduction. This study conducted an economic evaluation from a societal perspective of bilateral salpingectomies versus conventional sterilization techniques in the prevention of ovarian cancer., Study Design: We performed a micro-cost analysis comparing laparoscopic tubal coagulation, tubal clips and bilateral salpingectomies at the Michael Garron Hospital, formerly the Toronto East General Hospital, from 2015 to 2016. A Markov model was used in the cost-effectiveness and cost-utility analyses on these surgical procedures in ovarian cancer prevention. Costs were derived for the number ovarian cancer cases observed per sterilization method, cancer treatment, and associated procedural costs over each cancer patient's lifetime. The number of bilateral salpingectomies required to prevent an additional ovarian cancer case with the recommended treatment was also estimated., Results: Bilateral salpingectomies performed at the Michael Garron Hospital generated savings of $7823 per life-year gained (95% CI $3248-$10 190; incremental cost [ΔC] -$907, incremental effect [ΔE] 0.11 life-years gained) compared with tubal clips and savings of $6315 per life-year gained (95% CI -$6360 to $9342; ΔC -$755, ΔE 0.11 life-years gained) compared with tubal coagulation. Most importantly, for every 150 bilateral salpingectomies performed, one case of ovarian cancer may be prevented., Conclusion: Laparoscopic bilateral salpingectomy is the dominant, cost-effective surgical strategy when compared to tubal clips and tubal coagulation to prevent ovarian cancer. Laparoscopic bilateral salpingectomies reduce costs and enhance quality-adjusted life-years relative to the two alternative treatments., (Copyright © 2018 Society of Obstetricians and Gynaecologists of Canada. Published by Elsevier Inc. All rights reserved.)

Objectives: Data suggesting a link between the fallopian tube and ovarian cancer have led to an increase in rates of salpingectomy at the time of pelvic surgery, a practice known as opportunistic salpingectomy (OS). However, the potential benefits, risks and costs for this new practice are not well established. Our objective was to assess the cost-effectiveness of opportunistic salpingectomy at the time of laparoscopic permanent contraception or hysterectomy for benign indications., Methods: We created two models to compare the cost-effectiveness of salpingectomy versus usual care. The hypothetical study population is 50,000 women aged 45 undergoing laparoscopic hysterectomy with ovarian preservation for benign indications, and 300,000 women aged 35 undergoing laparoscopic permanent contraception. SEER data were used for probabilities of ovarian cancer cases and deaths. The ovarian cancer risk reduction, complication rates, utilities and associated costs were obtained from published literature. Sensitivity analyses and Monte Carlo simulation were performed, and incremental cost-effectiveness ratios (ICERs) were calculated to determine the cost per quality adjusted life year (QALY) gained., Results: In the laparoscopic hysterectomy cohort, OS is cost saving and would yield $23.9 million in health care dollars saved. In the laparoscopic permanent contraception cohort, OS is cost-effective with an ICER of $31,432/QALY compared to tubal ligation, and remains cost-effective as long as it reduces ovarian cancer risk by 54%. Monte Carlo simulation demonstrated cost-effectiveness with hysterectomy and permanent contraception in 62.3% and 55% of trials, respectively., Conclusions: Opportunistic salpingectomy for low-risk women undergoing pelvic surgery may be a cost-effective strategy for decreasing ovarian cancer risk at time of hysterectomy or permanent contraception. In our model, salpingectomy was cost-effective with both procedures, but the advantage greater at time of hysterectomy., (Copyright © 2017. Published by Elsevier Inc.)

Background: This study evaluated healthcare costs of index procedures and during a 6-month follow-up of women who had hysteroscopic sterilization (HS) versus laparoscopic bilateral tubal ligation (LBTL)., Materials and Methods: Women (18-49 years) with claims for HS and LBTL procedures were identified from the MarketScan commercial claims database (January 1, 2010, to December 31, 2012) and placed into separate cohorts. Demographics, characteristics, index procedure costs, and 6-month total healthcare costs and sterilization procedure-related costs were compared. Multivariable regression analyses were used to examine the impact of HS versus LBTL on costs., Results: Among the study population, 12,031 had HS (mean age: 37.0 years) and 7286 had LBTL (mean age: 35.8 years). The majority (80.9%) who had HS underwent the procedure in a physician's office setting. Fewer women who had HS versus LBTL received the procedure in an inpatient setting (0.5% vs. 2.1%), an ambulatory surgical center setting (5.0% vs. 23.8%), or a hospital outpatient setting (13.4% vs. 71.9%). Mean total cost for the index sterilization procedure was lower for HS than for LBTL ($3964 vs. $5163, p < 0.0001). During the 6-month follow-up, total medical and prescription costs for all causes ($7093 vs. $7568, p < 0.0001) and sterilization procedure-related costs ($4971 vs. $5407, p < 0.0001) were lower for women who had HS versus LBTL. Multivariable regression results confirmed that costs were lower for women who had HS versus LBTL., Conclusions: Among commercially insured women in the United States, HS versus LBTL is associated with lower average costs for the index procedure and lower total healthcare and procedure-related costs during 6 months after the sterilization procedure.

Permanent contraception is a highly desired and commonly used contraceptive option for women around the world who desire never to become pregnant. Current methods of female permanent contraception require surgery. Postpartum tubal ligation and interval surgical tubal ligation are safe and effective, do not interfere with menstrual cycles, and require no ongoing cost or medical checkups. Hysteroscopic tubal occlusion offers a less invasive surgical approach, but requires an imaging study for verification of correct placement. However, not all women have access to a surgeon trained to provide permanent contraception, or they may face other prohibitive logistic or financial burdens. The development of novel permanent contraception methods that are immediately effective and/or nonsurgical could help improve access to and acceptability of permanent contraception. The expansion of permanent contraception options could help women achieve their family planning goals and reduce unintended pregnancies., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To compare cost and efficacy of tubal anastomosis to in vitro fertilization (IVF) in women who desired fertility after a tubal ligation., Design: Cost-effectiveness analysis., Setting: Not applicable., Patient(s): Not applicable., Intervention(s): Not applicable., Main Outcome Measure(s): Cost per ongoing pregnancy., Result(s): Cost per ongoing pregnancy for women after tubal anastomosis ranged from $16,446 to $223,482 (2014 USD), whereas IVF ranged from $32,902 to $111,679 (2014 USD). Across maternal age groups <35 and 35-40, years tubal anastomosis was more cost effective than IVF for ongoing pregnancy. Sensitivity analyses validated these findings across a wide range of ongoing pregnancy probabilities as well as costs per procedure., Conclusion(s): Tubal anastomosis was the most cost-effective approach for most women less than 41 years of age, whereas IVF was the most cost-effective approach for women aged ≥41 years who desired fertility after tubal ligation. A model was created that can be modified based on cost and success rates in individual clinics for improved patient counseling., (Copyright © 2015 American Society for Reproductive Medicine. All rights reserved.)

Sterilization, male and female combined, is the most common use of contraception in the United States. Despite the lower risk, higher cost-efficacy, and high efficacy of vasectomy compared with female sterilization, more US women rely on female sterilization than male sterilization. Reasons for low use of vasectomy include lack of knowledge and misconceptions about the procedure, lack of access, provider bias, and patient preferences. This article will provide a basic overview of male and female sterilization, an exploration of vasectomy barriers, and ways obstetrician-gynecologists can increase vasectomy uptake including regular recommendation of vasectomy to patients in long-term committed relationships considering sterilization.

Objective: Tubal sterilization remains one of the most commonly requested contraceptive methods in the United States. Catholic hospital policy prohibits all sterilizations, but this ban is not uniformly enforced. We conducted this study to assess obstetrician-gynecologists' beliefs and experiences with tubal ligation in Catholic hospitals., Study Design: We interviewed 31 obstetrician-gynecologists geographically dispersed throughout the US who responded to a national survey and agreed to be contacted for a follow-up interview or who were referred by colleagues from the survey sample. Twenty-seven had experienced working in a Catholic hospital. Interviews were open ended and guided by a semistructured instrument. Transcripts were thematically analyzed., Results: Obstetrician-gynecologists disagreed with strict prohibition of sterilizations, especially when denying a tubal ligation placed the patient at increased medical risk. Cesarean delivery in Catholic hospitals raised frustration for obstetrician-gynecologists when the hospital prohibited a simultaneous tubal ligation and, thus, sent the patient for an unnecessary subsequent surgery. Obstetrician-gynecologists described some hospitals allowing tubal ligations in limited circumstances, but these workarounds were vulnerable to changes in enforcement. Some obstetrician-gynecologists reported that Catholic policy posed greater barriers for low-income patients and those with insurance restrictions., Conclusion: Obstetrician-gynecologists working in Catholic hospitals in this study did not share the Church's beliefs on sterilization. Research to understand patients' experiences and knowledge of their sterilization options is warranted in order to promote women's autonomy and minimize risk of harm., Implications Statement: Tubal sterilization, even when medically indicated or in conjunction with cesarean delivery, is severely restricted for women delivering in Catholic hospitals. For women whose only access to hospital care is at a Catholic institution, religious policies can prevent them from receiving a desired sterilization and place them at risk for future undesired pregnancy., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Oregon and federal laws prohibit giving informed consent for permanent contraception when presenting for an abortion. The primary objective of this study was to estimate the number of unintended pregnancies associated with this barrier to obtaining concurrent tubal occlusion and abortion, compared with the current policy, which limits women to obtaining interval tubal occlusion after abortion. The secondary objectives were to compare the financial costs, quality-adjusted life years, and the cost-effectiveness of these policies., Study Design: We designed a decision-analytic model examining a theoretical population of women who requested tubal occlusion at time of abortion. Model inputs came from the literature. We examined the primary and secondary outcomes stratified by maternal age (>30 and <30 years). A Markov model incorporated the possibility of multiple pregnancies. Sensitivity analyses were performed on all variables and a Monte Carlo simulation was conducted., Results: For every 1000 women age <30 years in Oregon who did not receive requested tubal occlusion at the time of abortion, over 5 years there would be 1274 additional unintended pregnancies and an additional $4,152,373 in direct medical costs. Allowing women to receive tubal occlusion at time of abortion was the dominant strategy. It resulted in both lower costs and greater quality-adjusted life years compared to allowing only interval tubal occlusion after abortion., Conclusion: Prohibiting tubal occlusion at time of abortion resulted in an increased incidence of unintended pregnancy and increased public costs., (Copyright © 2014 Mosby, Inc. All rights reserved.)

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1-1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1-1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5-1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance. Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend "neutralizing" the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non -mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not., (Copyright © 2014 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

The need for contraceptive and family planning services is often unmet, especially among lower-income women. However, the history of the provision of these services is fraught with coercion and mistrust: in 1979, in response to forced sterilization practices among doctors working with poor and minority populations, the U.S. Department of Health, Education, and Welfare imposed regulations on the informed consent process for Medicaid recipients requesting sterilization. The government mandated, among other requirements, a 30-day waiting period between consent and surgery and proscribed laboring women from providing consent. Initially intended to prevent the exploitation of poor women, these rules have instead become a barrier to many women receiving strongly desired, effective, permanent contraception. More critically, the regulations are ethically flawed: by preventing women from accessing needed family planning services, the Medicaid consent rules violate the standards of beneficence and nonmaleficence; by treating publically insured women differently from privately insured women, they fail the justice standard; and by placing constraints on women's free choice of contraceptive methods, they run afoul of the autonomy standard. The current federal sterilization consent regulations warrant revising. The new rules must simultaneously reduce barriers to tubal ligation while safeguarding the rights of women who have historically suffered mistreatment at the hands of the medical profession. These goals could best be obtained through a combined approach of improved clinician ethics education and a new standardized sterilization consent policy, which applies to all women and which abolishes the 30-day waiting period and the prohibition on obtaining consent in labor.

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., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: The aim was to elucidate the costs and clinical results of sterilization., Material and Methods: A retrospective analysis was carried out on sterilizations conducted at the Hyvinkää hospital in 2006 to 2007 by tubal ligation with clips and by microimplants., Results: Total costs obtained for microimplant sterilization per patient were 1,146 Euros and for clip sterilization 1,712 Euros. Postoperative pain was significantly less in the microimplant group, and adverse effects associated with the procedure were more common in the clip sterilization group., Conclusions: Microimplant sterilization performed on an outpatient basis is more cost-effective than laparoscopic clip sterilization.

Background: Hysteroscopic tubal sterilization is a minimally invasive alternative to laparoscopic tubal ligation for women who want permanent contraception. The procedures involves non-surgical placement of permanent microinserts into both fallopian tubes. Patients must use alternative contraception for at least 3 months postprocedure until tubal occlusion is confirmed. Compared to tubal ligation, potential advantages of the hysteroscopic procedure are that it can be performed in 10 minutes in an office setting without the use of general or even local anesthesia., Objective: The objective of this analysis was to determine the effectiveness and safety of hysteroscopic tubal sterilization compared with tubal ligation for permanent female sterilization., Data Sources: A standard systematic literature search was conducted for studies published from January 1, 2008, until December 11, 2012., Review Methods: Observational studies, randomized controlled trials (RCTs), systematic reviews and meta-analyses with 1 month or more of follow-up were examined. Outcomes included failure/pregnancy rates, adverse events, and patient satisfaction., Results: No RCTs were identified. Two systematic reviews covered 22 observational studies of hysteroscopic sterilization. Only 1 (N = 93) of these 22 studies compared hysteroscopic sterilization to laparoscopic tubal ligation. Two other noncomparative case series not included in the systematic reviews were also identified. In the absence of comparative studies, data on tubal ligation were derived for this analysis from the CREST study, a large, multicentre, prospective, noncomparative observational study in the United States (GRADE low). Overall, hysteroscopic sterilization is associated with lower pregnancy rates and lower complication rates compared to tubal ligation. No deaths have been reported for hysteroscopic sterilization., Limitations: A lack of long-term follow-up for hysteroscopic sterilization and a paucity of studies that directly compare the two procedures limit this assessment. In addition, optimal placement of the microinsert at the time of hysteroscopy varied among studies., Conclusions: Hysteroscopic sterilization is associated with: lower pregnancy rates compared to tubal ligation (GRADE very low); lower complication rates compared to tubal ligation (GRADE very low); no significant improvement in patient satisfaction compared to tubal ligation (GRADE very low)., Plain Language Summary: Hysteroscopic tubal sterilization is a minimally invasive alternative to conventional tubal ligation for women who want a permanent method of contraception. Both approaches involve closing off the fallopian tubes, preventing the egg from moving down the tube and the sperm from reaching the egg. Tubal ligation is a surgical procedure to tie or seal the fallopian tubes, and it usually requires general anesthesia. In contrast, hysteroscopic tubal sterilization can be performed in 10 minutes in an office setting without general or even local anesthesia. A tiny device called a microinsert is inserted into each fallopian tube through the vagina, cervix, and uterus without surgery. An instrument called a hysteroscope allows the doctor to see inside the body for the procedure. Once the microinserts are in place, scar tissue forms around them and blocks the fallopian tubes. Health Quality Ontario conducted a review of the effectiveness and safety of hysteroscopic tubal sterilization compared to tubal ligation. This review indicates that hysteroscopic tubal sterilization is associated with: lower pregnancy rates compared to tubal ligation; lower complication rates compared to tubal ligation; no significant improvement in patient satisfaction compared to tubal ligation. However, we found a number of limitations to the studies available on hysteroscopic tubal sterilization. Among other concerns, most studies did not include long-term follow-up and only 1 study directly compared hysteroscopic tubal sterilization to tubal ligation.

Background: Hysteroscopic sterilization is a minimally invasive alternative to laparoscopic tubal ligation for women who want permanent contraception. In contrast to the laparoscopic technique, a hysteroscope is used to pass permanent microinserts through the cervix and place them in the fallopian tubes. This procedure does not require local or general anesthesia and can be performed in an office setting., Objectives: The objective of this analysis was to determine, based on published literature, the cost-effectiveness of hysteroscopic tubal sterilization (HS) compared with laparoscopic tubal ligation (LS) for permanent female sterilization., Data Sources: A systematic literature search was conducted for studies published between January 1, 2008, and December 11, 2012., Review Methods: Potentially relevant studies were identified based on the title and abstract. Cost-utility analyses (studies that report outcomes in terms of costs and quality-adjusted life-years) were prioritized for inclusion. When not available, cost-effectiveness, cost-benefit, and cost-consequence analyses were considered. Costing studies were considered in the absence of all other analyses., Results: A total of 33 abstracts were identified. Three cost analyses were included. A retrospective chart review from Canada found that HS was $111 less costly than LS; a prospective activity-based cost management study from Italy reported that it was €337 less costly than LS; and the results of an American decision model showed that HS was $1,178 less costly than LS., Limitations: All studies had limited applicability to the Ontario health care system due to differences in setting, resource use, and costs., Conclusions: Three cost analyses found that, although the HS procedure was more expensive due to the cost of the microinserts, HS was less costly than LS overall due to the shorter recovery time required., Plain Language Summary: Hysteroscopic sterilization is a minimally invasive alternative to conventional tubal ligation for women who want a permanent method of contraception. Both approaches involve closing off the fallopian tubes, preventing the egg from moving down the tube and the sperm from reaching the egg. Tubal ligation is a surgical procedure to tie or seal the fallopian tubes, and it usually requires general anesthesia. In contrast, hysteroscopic tubal sterilization can be performed in 10 minutes in an office setting without general or even local anesthesia. A tiny device called a microinsert is inserted into each fallopian tube through the vagina, cervix, and uterus without surgery. An instrument called a hysteroscope allows the doctor to see inside the body for the procedure. Once the microinserts are in place, scar tissue forms around them and blocks the fallopian tubes. Health Quality Ontario commissioned a systematic review of published economic literature to determine whether hysteroscopic sterilization is cost-effective compared to tubal ligation. This review did not find any studies that reported results in terms of both costs and effectiveness or costs and quality-adjusted life-years. We did find 3 costing studies and included them in our review. All of these studies found that when hysteroscopic sterilization was performed as an outpatient procedure, it was less expensive than tubal ligation due to a shorter recovery time. However, none of the studies apply directly to Ontario because of differences in our health care system compared to those in the studies.

Objective: To compare transvaginal with laparoscopic tubal sterilization with respect to invasiveness and outcomes., Method: The outcomes of 103 patients who received interval tubal sterilization were compared. Group A (n = 38) underwent the transvaginal approach, group B (n = 38) a laparoscopic approach, and group C (n = 27) underwent mini-laparotomy due to difficulties encountered in one of the other procedures., Results: There were no significant differences in patient age between the groups. There was no significant difference in operative time or blood loss between groups A and B. Operative time was significantly longer in group C (120 ± 35 min) than group A (40 ± 5 min) or group B (45 ± 9 min) (p < 0.05). Blood loss was significantly greater in group C (120 ± 30 ml) than in group A (10 ± 2 ml) or group B (10 ± 1 ml) (p < 0.05). The cost of transvaginal tubal sterilization was the lowest, and that of mini-laparotomy was the highest. There was no contraception failure in any group., Conclusions: Transvaginal tubal sterilization is technically more difficult, but when correctly performed it is not associated with an increased complication rate, and is less costly than laparoscopic sterilization.

Objective: To track outcomes of women in three cohorts-those who requested postpartum tubal ligation and received the procedure (postpartum tubal ligation [PPTL] YES), those who requested postpartum tubal ligation but did not receive the procedure (PPTL NO), and a control group (those who did not request postpartum tubal ligation)-for 1 year postpartum., Methods: This was a record review evaluating women who delivered a liveborn singleton between December 2007 and May 2008 at the University of Texas San Antonio. Those in the case group were monitored until 1 year postdelivery. The primary outcome was pregnancy within 1 year of the index delivery among women in the control group compared with those in the PPTL NO group. Secondary outcomes included birth control requested at obstetric-admission discharge, attendance at a postpartum or other gynecology visit, contraceptive use between delivery and the postpartum visit, and request for contraception at the postpartum visit among the three cohorts., Results: During the observation period, 429 of 1,460 women requested postpartum tubal ligation; 296 (69%) received the procedure and 133 (31%) did not. Within 1 year of the index delivery, 46.7% of women in the PPTL NO group became pregnant compared with 22.3% of those in the control group (P<.001). Attendance at the postpartum visit was lowest for women in the PPTL YES group (12.8%; P=.004) compared with the similarly low attendance among those in the PPTL NO (18.8%) and control groups (20.3%; P=.73). Women in the PPTL NO group and those in the control group selected similar methods of postpartum contraception at hospital discharge., Conclusion: Women who did not receive a requested postpartum tubal ligation were more likely to become pregnant within 1 year of delivery than were those in the control group (women not requesting permanent sterilization)., Level of Evidence: II.

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.

Objective: To determine individual and delivery characteristics of women least likely to obtain a requested postpartum tubal ligation (PPTL) and, secondarily, to compare the postpartum contraceptive choices of women with an unfulfilled sterilization request to women not requesting a PPTL., Study Design: Record review ofwomen delivering a liveborn singleton between December 2007 and May 2008 at the University of Texas San Antonio. Primary outcomes were risk factors for not receiving a requested PPTL. Secondary outcome was to compare the postpartum contraceptive choices of women not receiving a PPTL to controls, women not requesting a PPTL., Results: During the observation period, 429 of 1,460 women requested a PPTL; 296 (69%) received the procedure, and 133 (31%) did not. The majority of patients (332/429, 77.4%) were Hispanic. Pretest power analysis concluded that 107 women were required in each group. Cesarean delivery was associated with the highest likelihood of receiving a PPTL. Women receiving a PPTL were more likely (p < or = 0.05) to be a documented U.S. resident, married, of lower parity, have private or any medical insurance and to have received any prenatal care. Postpartum contraception among women with unfulfilled sterilization requests was similar to that among controls., Conclusion: Although financial and policy barriers exist, the majority of patients requesting a PPTL received the procedure.

Objectives: Law no. 2001-588 of 4 July 2001 liberalised the practice of tubal sterilisation in France, at the same time as a new hysteroscopic method of female sterilization appeared. The growth of this method has been spurred by the reduced need for analgesia, absence of incision and scar, reduced duration of hospitalization and diminution of costs. The aim of this study was to analyse the use of the Essure procedure in France., Patients and Methods: This multicentre study covered seven French facilities from January 2004 through June 2006. This study included 1061 attempted placements of the Essure micro-insert, marketed by Conceptus SAS (France)., Results: The first placement attempt was successful in 992 cases (94.4%). The success rate for second attempts was 59% (n = 23). Mean VAS was 3,23 +/- 0.19. Ninety-three percent of patients undergoing Essure placement were satisfied or very satisfied., Discussion and Conclusion: Tubal sterilisation with Essure micro-inserts is a reliable and reproducible method that requires a short period of training. In the future, the hysteroscopic pathway will replace the laparoscopic route.

By using the activity-based cost/management (ABC/M) system we computed and compared costs needed for laparoscopic tubal sterilization (LTS) and Essure hysteroscopic tubal occlusion (EHTO). We found that total health costs related to consultation and presurgery did not differ between LTS and EHTO; EHTO has low recovery unit costs but is more costly for the operating theater, mainly due to Essure microinserts.

Background: To assess the change in hospital reimbursement resulting from a 2004 policy requiring immigrants with Emergency Medicaid (EM) to pay for sterilization following vaginal delivery, we examined rates of tubal ligation following vaginal [postpartum bilateral tubal ligation (PPBTL)] and cesarean [cesarean section with bilateral tubal ligation (CSBTL)] deliveries, and compared these to a Standard Medicaid (SM) population unaffected by the policy., Study Design: Records of women who delivered at the Oregon Health and Science University between January 2000 and December 2006 were reviewed. Data examined included insurance, mode of delivery, sterilization and net revenue by delivery type., Results: A total of 3612 SM patients and 4220 EM patients delivered in the 5 years before the policy, and 1628 SM patients and 2066 EM patients delivered in the 2 years after the policy. The incidence of PPBTL among EM patients delivering vaginally dropped from 9.9% prepolicy to 0.9% postpolicy (p<.01). Concurrently, CSBTL among EM patients having cesarean section increased from 18.8% prepolicy to 23.5% postpolicy (p=.03). Notably, no significant change in PPBTL (pre: 8.7%, post: 9.2%, p=1.0) or CSBTL (pre: 22.9%, post: 22.9%, p=.62) occurred in the SM group. The net revenue change for all deliveries with tubal ligations in the EM population postpolicy was -US$5284., Conclusion: Requiring out-of-pocket payment for sterilization following vaginal delivery in an EM population results in a decrease in PPBTL and an increase in CSBTL, and does not reduce hospital financial losses.

Objective: To analyze the financial implications of establishing a hysteroscopic sterilization program using the Essure micro-insert tubal sterilization system in an ambulatory clinic., Methods: A retrospective cohort study (Canadian Task Force classification Type II-2), in an ambulatory women's health clinic in a tertiary hospital, of 108 women undergoing Essure coil insertion between 2005 and 2006, and 104 women undergoing laparoscopic tubal sterilization for permanent sterilization between 2001 and 2004. The Essure procedures used a 4 mm single channel operative hysteroscope and conscious sedation (fentanyl and midazolam); the laparoscopic tubal sterilizations were completed under general anaesthesia with a 7 mm laparoscope and either bipolar cautery or Filshie clips. Costs associated with the procedure, follow-up, and management of any complications (including nursing, hospital charges, equipment, and disposables) were tabulated., Results: The Essure coils were successfully placed on the first attempt in 103 of 108 women (95%). Three patients required a second attempt to complete placement and two patients required laparoscopic tubal sterilization after an unsuccessful Essure. All 104 laparoscopic tubals were completed on the first attempt with no complications reported. The total cost for the 108 Essure procedures, including follow-up evaluation, was $138,996 or $1287 per case. The total cost associated with the 104 laparoscopic tubal sterilization procedures was $148,227 or $1398 per case. The incremental cost-effectiveness ratio was $111., Conclusions: The Essure procedure in an ambulatory setting resulted in a statistically significant cost saving of $111 per sterilization procedure. Carrying out the Essure procedure in an ambulatory setting frees space in the operating room for other types of cases, improving access to care for more patients.

Background: Long-acting reversible contraceptive (LARC) methods are highly effective in preventing unintended pregnancies. However, their uptake is low in much of the developed world. This study aimed at assessing the cost-effectiveness of LARC methods from the British National Health Service (NHS) perspective., Methods: A decision-analytic model was constructed to estimate the relative cost-effectiveness of the copper intrauterine device (IUD), the levonorgestrel intrauterine system (LNG-IUS), the etonogestrel subdermal implant and the depot medroxyprogesterone acetate injection (DMPA). Comparisons with the combined oral contraceptive pill (COC) and female sterilization were also performed. Effectiveness data were derived from a systematic literature review. Costs were based on UK national sources and expert opinion., Results: LARC methods dominated COC (i.e. they were more effective and less costly). Female sterilization dominated LARC methods beyond 5 years of contraceptive protection. DMPA and LNG-IUS were the least cost-effective LARC methods. The incremental cost-effectiveness ratio of implant (most effective LARC method) versus IUD (cheapest LARC method) was pound13 206 per unintended pregnancy averted for 1 year of use and decreased until implant dominated IUD in 15 years. Discontinuation was a key determinant of the cost-effectiveness of LARC methods., Conclusions: LARC methods are cost-effective from the British NHS perspective. Practices improving user satisfaction and continuation of LARC method use should be identified and promoted.

This article will cover current contraceptive use around the world, then examine the advantages and disadvantages of female sterilization, the hormonal intrauterine system and the copper intrauterine device. Finally, the need for contraceptive choice will be discussed along with a discussion on the cost-effectiveness of these methods.

Study Objective: To compare the institutional cost of permanent female sterilization by Essure hysteroscopic sterilization and laparoscopic bilateral coagulation., Design: Retrospective cohort study (Canadian Task Force classification II-2)., Setting: Midwestern academic medical center., Patients: Women of reproductive age who elected for permanent contraception by the Essure method (n = 43) or by laparoscopic tubal coagulation (n = 44) during the time frame studied., Interventions: Placement of the Essure inserts according to the manufacturer's instructions or laparoscopic tubal sterilization using bipolar forceps according to standard techniques of open or closed laparoscopy., Measurements and Main Results: Cost-center data for the institutional cost of the procedure was abstracted for each patient included in the study. In addition, demographic data and procedural information were obtained and compared for the patient populations. The Essure system of hysteroscopic sterilization had a significantly decreased cost compared with laparoscopic tubal sterilization when both procedures were performed in an operating room setting. The decrease per patient in institutional cost was 180 dollars (p = .038). This included the cost of the confirmatory hysterosalpingogram 3 months after Essure placement and the cost of laparoscopic tubal occlusion by Filshie clip if the Essure micro-inserts could not be placed. The majority of the cost was related to hospital costs as opposed to physician costs. The Essure procedure had higher costs for disposable equipment (p <.0001), but this was offset by higher charges for operating room costs, which included the recovery room (p <.0001) and pharmacy costs (p <.0001) in the patients in the laparoscopy group., Conclusion: In our setting, the Essure hysteroscopic sterilization had significant cost savings compared with laparoscopic tubal sterilization (p = .038). We believe that our data represent the minimum of potential savings using this approach, and future developments will only increase the cost difference found in our study.

Objective: To determine the diagnostic accuracy of cytology smears in distinguishing between tube and non-tube structures., Methods: One hundred cytology smears of fallopian tube and non-tube structures (vessels, round and ovarian ligaments) were prepared from surgically removed uterus and fallopian tube specimens and stained by the Papanicolaou method. The slides were reviewed blindly by pathologists and interpreted as tube or non-tube structures. The results were compared to the histological examination of the same specimens., Findings: Results indicated an overall accuracy of 97% with a specificity of 98% and sensitivity of 96% for cytology smears, taking histology as the gold standard. Positive and negative predictive values were 96.1% and 97.9%, respectively., Conclusion: Cytology smears are a convenient and cost effective tool for laboratory confirmation of tubal sterilization. This method can reduce the costs of laboratory examination, especially in developing countries, where tubal sterilizations are done in large cohorts. However, histological slides remain the gold standard in cases of medicolegal problems.

Study Objective: To evaluate the actual cost difference in performing Essure hysteroscopic sterilization in the office compared with ambulatory surgery using laparoscopic sterilization in the operating room., Design: Cost-comparison analysis (Canadian Task Force classification III)., Setting: University hospital and affiliated outpatient office., Interventions: Hysteroscopic placement of Essure device in an office setting and laparoscopic tubal ligation for permanent sterilization., Measurements and Main Results: The various costs associated with the two procedures at our institution were compiled, and a direct cost comparison was made. We used actual institutional costs of the procedures, not billing or reimbursement. We found laparoscopic tubal ligations to cost 3449 dollars compared with hysteroscopic placement of the Essure device that costs 1374 dollars yielding a 2075 dollars difference between the procedures., Conclusion: In our institution and in our experience, office-hysteroscopic placement of the Essure device is a more cost-effective method than laparoscopic tubal ligation.

Study Objective: To compare the costs of tubal anastomosis performed by laparoscopy and by laparotomy., Design: Cost analysis study using the hospital administrative database (Canadian Task Force classification II-2)., Setting: University teaching hospital., Patients: Eighty-nine women. Intervention. Tubal anastomosis by laparoscopy (43) and by laparotomy (46)., Measurements and Main Results: Tubal anastomosis took longer when performed by laparoscopy than by laparotomy; however, the total time patients spent in the operating room was similar. Women treated by laparoscopy spent more time in the recovery room. Labor costs for nurses in the operating room and recovery room costs were significantly higher in the laparoscopy group. Costs for operating room supplies were similar. Pharmacy costs and expenses in the ward were lower in the laparoscopy group. The mean total cost for laparoscopic tubal anastomosis was $861 +/- 137 and for laparotomy was $1348 +/- 188 (p <0.001)., Conclusion: Laparoscopic tubal anastomosis costs less than tubal anastomosis by laparotomy.

To determine the cost-effectiveness of seven contraceptive methods from the providers' perspective, the cost per adjusted couple-years of protection (ACYP) was calculated for each method based on region-specific conversion factors. More than 74,800 ACYPs were provided during March 1999 to February 2000. Intrauterine devices and implants offered the highest and lowest ACYP respectively. Condom was the single most expensive contraceptive method. Vasectomy was the most cost-effective method and implant provided the highest cost per ACYP.

Objective: To compare micro-laparoscopic surgical sterilization and standard laparoscopic sterilization with respect to cost effectiveness and patient preferences., Study Design: A retrospective study of all laparoscopic surgical sterilizations performed under general anesthesia at Johns Hopkins Bayview Medical Center--16 micro-laparoscopies and 34 standard laparoscopies. Cases selected for review were limited to patients undergoing surgical contraception and not requiring additional, concurrent procedures. Laparoscopic surgical sterilization was performed using a double-puncture technique with silicone band application. In each case either a standard, 10-mm laparoscope or a 2-mm micro-laparoscope was used, and the procedure was performed under general anesthesia. Postoperative pain management was achieved by nonsteroidal antiinflammatory drugs and/or narcotic analgesia. All cases were performed by residents under faculty supervision. Medical records and hospital billing records were reviewed, and a standardized telephone interview was conducted to assess postoperative quality of life and patient satisfaction., Results: Both techniques were comparable in cost effectiveness. There was no significant difference in operating room time, average operating room costs, average ancillary department costs, instrument and supply costs, or length of stay. Postoperative discomfort was significantly less with microlaparoscopy (P = .05), and patient satisfaction was higher in the microlaparoscopy group., Conclusion: Microlaparoscopy and the standard laparoscopic approach for surgical sterilization are associated with similar hospital charges. Postoperative pain and overall patient satisfaction were significantly better with microlaparoscopy than standard laparoscopy.

Unlabelled: The purpose of this review is to analyze critically the two techniques of sterilization (bilateral tubal ligation [BTL] and vasectomy) so that a physician may provide informed consent about methods of sterilization. A MEDLINE search and extensive review of published literature dating back to 1966 was undertaken to compare preoperative counseling, operative procedures, postoperative complications, procedure-related costs, psychosocial consequences, and feasibility of reversal between BTL and a vasectomy. Compared with a vasectomy, BTL is 20 times more likely to have major complications, 10 to 37 times more likely to fail, and cost three times as much. Moreover, the procedure-related mortality, although rare, is 12 times higher with sterilization of the woman than of the man. Despite these advantages, 300,000 more BTLs were done in 1987 than vasectomies. In 1987, there were 976,000 sterilizations (65 percent BTLs and 35 percent vasectomies) with an overall cost of $1.8 billion. Over $260 million could have been saved if equal numbers of vasectomies and BTLs had been performed, or more than $800 million if 80 percent had been vasectomies, as was the case in 1971. The safest, most efficacious, and least expensive method of sterilization is vasectomy. For these reasons, physicians should recommend vasectomy when providing counseling on sterilization, despite the popularity of BTL., Target Audience: Obstetricians & Gynecologists, Family Physicians, Learning Objectives: After completion of this article, the reader will be able to predict the failure rates and likelihood of successful reversal of tubal ligation and vasectomy; to recall the difference in cost between the two sterilization procedures, and to describe the short-term and long-term complications associated with each of the two methods of sterilization.

The study of a modified minilaparotomy technique of interval female sterilization is reported. The modified minilaparotomy technique of interval female sterilization is performed under local anesthesia using the Ramathibodi uterine manipulator, bivalve speculum, and a low midline incision. Sixty cases were treated with this technique. From the study, it was revealed that the mean age of patients +/- SD was 31.2 +/- 5.6 years, the mean body weight +/- SD was 43.3 +/- 5.1 kg, and the mean height +/- SD was 152.1 +/- 8.2 cm. The mean operating time was 24.3 +/- 5.5 min with a range from 15 to 35 min. All patients recovered and were allowed home within 2 h after operation. No immediate or late complications were observed. It was concluded that this technique is quick, safe, inexpensive, and easy to perform as an outpatient procedure.

To optimize the time spent counseling a sterilization patient, this article presents a 10-step process that includes all steps necessary to ensure a comprehensive counseling session: (1) Discuss current contraception use and all available methods; (2) assess the client's interest in/readiness for sterilization; (3) emphasize that the procedure is meant to be permanent, but there is a possibility of failure; (4) explain the surgical procedure using visuals, and include a discussion of benefits and risks; (5) explain privately to the client the need to use condoms if engaging in risky sexual activity; (6) have the client read and sign an informed consent form; (7) schedule an appointment for the procedure and provide the patient with a copy of all necessary paperwork; (8) discuss cost and payment method; (9) provide written preoperative and postoperative instructions; and (10) schedule a postoperation visit, or a postoperation semen analysis.

Objective: To compare the charges between laparoscopic sterilization performed under either local or general anesthesia in a traditional operating room setting with anesthesia personnel in attendance., Design: A retrospective review of charges., Setting: The Regional Medical Center, Memphis, Tennessee., Patients: Sixty-five women undergoing laparoscopic sterilization, 33 under local and 32 under general anesthesia. Interventions. Laparoscopic sterilization., Measurements and Main Results: Patient demographics, history of pelvic inflammatory disease, and history of previous surgery were similar for both groups. Operating room and recovery room times were shorter for patients whose procedures were performed under local anesthesia. Flat-rate fee schedules reduced the cost savings for cases performed under local anesthesia to $529 dollars per case, with 76% ($402) of the savings related to anesthetic drugs or equipment., Conclusion: Although these savings appear minimal on a per case basis, if 50% of the approximately 210,000 laparoscopic sterilizations performed in the United States each year were performed under local anesthesia, a savings of over $55 million could be achieved (105,000 cases X $529 = $55,545,000). This would result in substantial overall monetary savings to the health care system.

Despite the numerous painstaking evaluative trials that were conducted for more than two decades, hysteroscopic sterilization techniques remain more of a concept than a reality. However, it is likely that transcervical methods will continue to attract the investigator who is interested in simple, inexpensive outpatient office or female sterilization procedures in the clinic. Regardless, the cost of clinical trials, required follow-up, and preclinical toxicologic evaluations may continue to inhibit further research in this area.

Since 1972 I have introduced the following technical modifications in outpatient laparoscopy under local anesthesia to improve safety, economy, and patient acceptability: avoiding the insufflating needle and sharp trocar in favor of open abdominal entry, using the Hasson cannula; introducing room air for insufflation instead of nitrous oxide or carbon dioxide; using the Hulka clip in place of tubal coagulation; making a single-incision, open surgical entry through the central umbilical fossa in obese patients; and completing fascial penetration with a blunt hemostat or Kelly clamp to minimize the risk of bowel or vessel injury.

The objective of this analysis was to evaluate and compare the cost-effectiveness of eight contraceptive methods: condoms, diaphragms, oral contraceptives, intrauterine devices, medroxyprogesterone acetate suspension, levonorgestrel subdermal implants, tubal ligation and vasectomy. Based on a comprehensive review of the literature and various additional data sources, this analysis identified, measured and compared direct costs of the methods, physician visits, treatment of adverse effects and cost of failure (i.e., mean cost for all types of deliveries or first-trimester abortion). Medical benefits (if any) resulting from each contraceptive method were calculated and considered in the analysis as cost savings. The cost of method failure proved to be the greatest influence on cost-effectiveness. Sterilization was identified as the most cost-effective method overall. Of the reversible methods, the intrauterine device was found to be the most cost-effective, followed by levonorgestrel implants.

Between September 1986 and February 1992 we performed 210 laparoscopic tubal ligations in our office under local anesthesia using the Hulka clip. During the last 2 years we used a microchip video camera and endocoagulated the fallopian tubes adjacent to the clip in 84 women. The length of time for each procedure ranged from 15 to 30 minutes (average 20 min). There were no intraoperative complications. Failure to tolerate abdominal lifting (the "belly" test) was the only contraindication in this series. Previous abdominal surgery was not a contraindication. The three known failures in our first 69 cases were thought to be inaccurate clip applications. Subsequently, we added endocoagulation to the technique. Our procedure is cost efficient and time saving for both patients and physicians.

Over the last 15 years female sterilization by the vaginal route has been abandoned in favour of the abdominal approach via a laparoscope or a suprapubic incision. This was justified when the vaginal route was used for a fimbriectomy or a Pomeroy type of sterilization. The use of tubal occlusion methods designed for the laparoscope has simplified the technique of vaginal sterilization and lowered the morbidity. Four hundred and ninety consecutive cases over an 18-year period are reviewed. Four hundred and eighty five were completed vaginally. The methods used were Pomeroy with catgut, Falope ring, Hulka and Filshie clips. The Filshie clip was the most satisfactory. Vaginal sterilization is suitable for day care. The readmission rate was 1%. There was no case of pelvic infection in 177 clip cases but 5 in 173 where the Pomeroy technique was used. The pregnancy rate was highest with the Hulka clip. The overall rate was 1%. With clip methods strong analgesics were only required in 6% postoperatively and only 14% took any analgesic after returning home; consequently return to normal activities was rapid. The patient's weight was not related to operative difficulty when clips were used so the vaginal route may prove to be the method of choice in the obese. Filshie clip sterilization via the posterior fornix of the vagina could be the most cost-effective method of sterilization available at present. The vaginal route needs reappraisal using contemporary methods of tubal occlusion.

A prospective, randomized study comprised 125 outpatient laparoscopic sterilization patients who had received either general anaesthesia or local anaesthesia together with intravenous sedation. The patients who had received local anaesthesia suffered significantly less postoperative pain and sore throat. Recovery and discharge were similar in the two groups, but those given a general anaesthetic were more drowsy in the evening on the day of operation. The time spent in the operating theatre was significantly shorter for the group given local anaesthesia, and the costs were lower. The majority of patients from both groups would prefer local anaesthesia and sedation for a similar procedure in the future. We conclude that local anaesthesia by intravenous sedation is the method of choice for laparoscopic sterilization.

This paper presents a policy analysis of the impact of prohibiting Medicaid reimbursement funding for tubal ligations by indigent women, under 21 years of age. Because this population is dependent upon Medicaid funds, the freedom of self determination is limited. The current policy does not provide any alternative to the age rule, even if the patient is infected with a life-threatening disease, such as human immunodeficiency virus (HIV). The policy, therefore, creates serious problems for those individuals who choose to prevent a pregnancy under certain life-threatening circumstances. As the incidence of AIDS continues to increase, the absence of an age alternative for tubal ligations will become a problem of increasing practical and statistical significance. The conceptual framework for the analysis of Medicaid nonreimbursement for tubal ligations, with respect to age demands was adopted from the work of Gilbert and Specht, 1986. Four dimensions of choice are addressed: (1) the bases of social allocation, (2) the nature/type of social provisions, (3) the delivery system and (4) finances. Although all areas will be addressed, the major emphasis will be placed on social allocation.