Dr. Cass on salpingectomy - Part 1

DR. CASS: So, I gave a presentation today as a debate format - pro and con - with Barry Schwarz from Texas.  And the question that was posed to us was: Salpingectomy, should it be part of every routine tubal sterilization?  Yes or No?  And it was a wonderful opportunity to revisit the data, mostly in the context, as I say, of a patient who comes in wanting to have a tubal sterilization.  

The pro/con debate is a very nice format to look a little bit at some of the arguments for a practice that quite frankly has been adopted very widely in the United States, sometimes I think without a lot of understanding as to why necessarily we should incorporate complete removal of the fallopian tube.  I think that we ended up having a very practical discussion and conversation around what some of the data shows, but also some of the potential flaws. Namely, we still, in 2019, have no prospective studies that have actually definitively documented that removing the entire fallopian tube actually does achieve the desired effect, which is ovarian cancer reduction.  

Now reducing ovarian cancer in and of itself is a very lofty and important goal.  But the reality is ovarian cancer is still fairly rare.  So this practice--which is very practical of removing the entire fallopian tube, very feasible at the time of tubal sterilization for the most part, has not been shown to add too much cost, minimal impact on blood loss and no real long-term complications--clearly make sense for the high-risk patient, a woman who has by virtue of family history or a genetic predisposition a risk of developing ovarian cancer.  But the question is, what about the low-risk population, the general population, which is really what most of these providers are going to be doing in their offices.  And so that was really where the debate centered today.  

My position in the debate, which I do actually very much advocate in practice, is that yes, salpingectomy should be part of routine sterilization to remove the entire fallopian tube.  And I think that there are three really compelling reasons why this should become incorporated into practice.  

The first of which is we do have enough data to show from animal models, from our understanding of how ovarian cancer begins, that it’s actually the fallopian tube, which is probably the culprit in the majority of cases of ovarian cancer?  And we have really good data from very elegant models in animals as well as population-based studies as well as some actual data from retrospective populations that those women who had complete removal of the fallopian tubes actually in later life had a lower risk of developing ovarian cancer.  

Animal models which also show us that if you remove the fallopian tube in a mouse model that is sort of designed to look and smell and feel like ovarian cancer, that in fact these mice, if the tubes are removed, do not develop ovarian cancer.  

And then finally we have data to show that it’s not just about ovarian cancer reduction but also about two other really important topics, namely, after sterilization, women can have pain, hydrosalpinges pathology in the tube that is as a result of having manipulation of just a portion of the fallopian tube and, of course, there’s the question of ectopics.  So if you remove the entire fallopian tube, you virtually eliminate the risk or almost virtually eliminate the risk of having ectopic pregnancies and all of the anxiety and medical attention and care and sometimes surgical intervention that’s necessary plus you eliminate the risk of hydrosalpinges, which can necessitate further intervention. And then finally, the most compelling reason, your patient is coming to you because she wants to not get pregnant.  And we know that tubal ligations, even performed in the best hands, can fail.  Remove the entire fallopian tube and you can’t get pregnant.