Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC; Lineberger Comprehensive Cancer Center, Chapel Hill, NC.
Am J Obstet Gynecol. 2019 Jan;220(1):106.e1-106.e10. doi: 10.1016/j.ajog.2018.08.032. Epub 2018 Aug 28.
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.
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.
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.
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.
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.
在子宫切除术或间隔绝育时切除输卵管已成为预防卵巢癌的常规做法。虽然这种方法已经出现，但由于人们认为在剖宫产时进行这种手术会增加发病率和手术难度，而且这种情况下缺乏可用数据，因此在寻求永久性绝育的孕妇中，这种手术在剖宫产时的应用尚未得到广泛采用。
我们旨在进行一项成本效益分析，比较在剖宫产时进行长期绝育和降低卵巢癌风险的策略，包括双侧输卵管结扎术、机会性输卵管切除术和长效可逆避孕。
为在美国人群中进行剖宫产且希望永久性绝育的孕妇构建了决策分析和成本效益模型，比较了 3 种策略：（1）双侧输卵管结扎术，（2）双侧机会性输卵管切除术，和（3）产后长效可逆避孕。这个理论队列包括 110,000 名在剖宫产时希望永久性绝育并预防卵巢癌的孕妇，平均年龄为 35 岁，根据美国女性平均预期寿命为 75 岁，她们将再监测 40 年。主要结局指标是增量成本效益比。有效性以质量调整生命年来衡量。次要结局包括：卵巢癌病例和死亡数、手术相关并发症、意外妊娠和异位妊娠。进行了 1 、 2 、 3 种方式和蒙特卡罗概率敏感性分析。意愿支付阈值设定为 10 万美元。
双侧输卵管结扎术和剖宫产时双侧机会性输卵管切除术均具有有利的成本效益比。在基线分析中，与输卵管结扎术相比，输卵管切除术的增量成本效益比为每质量调整生命年 23,189 美元，更具成本效益。剖宫产术后长效可逆避孕并不具有成本效益（即，被主导）。虽然输卵管结扎术和输卵管切除术在广泛的成本和风险估计范围内都是具有成本效益的，但增量成本效益比分析对输卵管切除术降低癌症风险、围手术期并发症风险和成本的估计不确定性高度敏感。蒙特卡罗概率敏感性分析估计，输卵管结扎术成为比输卵管切除术更优策略的可能性为 49%。如果输卵管切除术的围手术期并发症风险确实比输卵管结扎术高 2%以上，或者输卵管切除术降低癌症风险的幅度小于 52%，那么输卵管结扎术是更优、更具成本效益的策略。
双侧输卵管结扎术和剖宫产时双侧机会性输卵管切除术都是永久性绝育和降低卵巢癌风险的有效策略。虽然输卵管结扎术和剖宫产时双侧机会性输卵管切除术都是寻求永久性绝育和降低癌症风险的剖宫产患者的合理策略，但阈值分析表明，在确定首选策略之前，需要更好地确定剖宫产时输卵管切除术的风险和获益。
