Cases in High Value Care

Sterilization: Postpartum tubal vs. interval laparoscopic tubal

Andrea Seid, MD
aseid@fresno.ucsf.edu
 

Clinical Scenario A
A 38 y.o. G7P6016 presents to clinic 5 weeks postpartum after a NSVD, she desires permanent sterilization and signed tubal consent 12 weeks prior to delivery. She declined LARCs and other contraceptive methods. She was scheduled for surgery 1 week later and had a laparoscopic tubal ligation. Patient returned to clinic 2 weeks after surgery for a post-operative appointment.

Clinical Scenario B
A 38 y.o. G7P6016 presented to L&D in labor, and is now status post NSVD.  Twelve weeks prior to delivery she signed a tubal consent form and still desires a tubal ligation. On postpartum day #1 a postpartum tubal ligation was performed, and patient was discharged on postpartum day #2. Patient was scheduled to return to clinic in 2-4 weeks for routine postpartum care.

Discussion Questions

  1. What barriers are there when scheduling a tubal ligation?
  2. Is there a difference in cost for laparoscopic tubal ligation styles?

Scenario A
Clinic visit
Level 3 Patient Pre-op/H&P  $131**
Level 3 Post-op follow up $131**
Facility: $3626
Physician: $718
Anesthesia: $702

Equipment         

Harmonic                                      $416/case
Titanium clip (Filshie clip)              $85/case
Bipolar (Kleppinger)                       $57/case
Silicone band (Falope-Ring)           $200/case
Monopolar                                     $45/case

Total: $5308 + equipment choice
$5046 (Healthcare Bluebook, n.d.)
**Amount charged by local billing department

Scenario B
Facility: $1877
Physician: $716
Anesthesia: $709
Equipment (suture) comparable to lap closure of port sites

Clinic visit
Level 3 Postpartum  $131**

Total: $3433
$3302 (Healthcare Bluebook, n.d.)
**Amount charged by local billing department

Teaching Moment:
Female sterilization remains the most common form of contraception; in 2006 643,000 procedures were performed.  The timing of sterilization depends on patient preference, acute risk, access to services and insurance coverage.   Methods of tubal ligation include: hysteroscopic occlusion, laparoscopy with electrocoagulation, mechanical occlusive devices, tubal excision, and mini-laparotomy (Amercian College of Obstetricians and Gynecologists, 2013).

Pregnancy rates by procedure are: postpartum partial salpingectomy (6.3/1000 over 5-years, ectopic 1.5/1000), bipolar (16.5/1000 over 5 years, ectopic 17.1/1000), silicone band (10.0/1000 over 5 years, ectopic 7.3/1000), spring clip (31.7/1000 over 5 years, ectopic 8.5/1000), titanium clip (9.7/1000 over 5-years, ectopic 1.7/1000). Total salpingectomy data is pending, monopolar has a rate of 7.5/1000 over 5-years. (Amercian College of Obstetricians and Gynecologists, 2013)

From this review, the most cost effective and effective method is postpartum tubal ligation.  Laparoscopically the monopolar tool is the most cost effective followed by bipolar, titanium clip, silicone band, and lastly the Harmonic.   In terms of pregnancy rates after tubal, postpartum partial salpingectomy, followed by monopolar, titanium clip, silicone band, bipolar, then spring clip are the most successful. Decisions regarding which method is utilized is highly dependent on the surgeon.  There are several barriers to performing a postpartum tubal ligation: patient personal choice, physical factors (weight/body habitus), comorbid conditions, and physician compensation.  Early antenatal assessment and identification if a patient is a candidate for postpartum tubal ligation should be performed in the prenatal visit.  Increasing awareness of the urgency to perform postpartum tubal ligations at facilities is recommended, as oftentimes postpartum tubal ligations are thought of as “elective” procedures and are not prioritized.  Of note: compared with abdominal approaches to female sterilization, vasectomy is safer, more effective and less expensive. (Amercian College of Obstetricians and Gynecologists, 2013)

At our local hospital the following costs are estimated:

Harmonic: The harmonic hand piece is roughly $400 but the harmonic cord that is required costs approximately $800 and is usable for approximately 50 surgeries.  Total cost: $416 per case 
Filshie clip:The clips require an applier which costs $2700 but can be reused indefinitely as long as the instrument is well taken care of.  Total cost: $85 
Bipolar:The cord and hand piece together are approximately $2000 and can be used for 30-40 cases. The third component, a generator, is a large purchase but is required in every operating room and was not included in the cost.  Total cost: $57
Silicone band:
 Fallopian Ring Appliers are $200.  Bands $65/pack Total cost: $265
Monopolar: 
Cord and hand piece cost approximately $1500 and can be used for 30-40 cases. Total cost: $45

Bibliography
Amercian College of Obstetricians and Gynecologists. (2013, 02). ACOG. Retrieved 10 24, 2016, from Benefits and Risks of Sterilization: http://www.acog.org/Resources-And-Publications/Practice-Bulletins/Committee-on-Practice-Bulletins-Gynecology/Benefits-and-Risks-of-Sterilization

Healthcare Bluebook. (n.d.). Retrieved 10 24, 2016, from Tubal Ligation: https://healthcarebluebook.com/page_ProcedureDetails.aspx?dataset=md&id=104&g=Tubal+Ligation&directsearch=true

Healthcare Bluebook. (n.d.). Retrieved 10 24, 2016, from Tubal Block or Tubal Ligation (laparoscopic): https://healthcarebluebook.com/page_ProcedureDetails.aspx?dataset=md&id=535&g=Tubal%20Block%20or%20Tubal%20Ligation%20
(laparoscopic)&directsearch=true

Penfield, A. (2000). The Filshie clip for female sterilizatoin: a review of world experience. Am J Obstet Gynecol, 182(3):485.

 

Date Published: 12/23/2016

Reviewers: Lauren Demosthenes, MD and Jennifer Keller, MD MPH

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