The postreproductive salpingectomy

13 12 2013

To the editor:

Findley et al. report (1) that simultaneous salpingectomy performed at the time of hysterectomy has no short-term negative effects on ovarian reserve. To add plausibility to this finding, we would like to point to the vascular connections: In the ovaries, blood supply is mainly secured via the arteria ovarica from the aorta and via the ramus ovaricus from the arteria uterina. These two arteries naturally anastomose with each other. A further branch of the arteria uterina, the ramus tubarius, connects the fallopian tube. During hysterectomy, the arteria uterina is ligated. Nevertheless, the central branch of the arteria ovarica in the infundibulopelvic ligament still guarantees sufficient blood flow from the aorta to the ovaries. A collateral connection of the remaining branch of the ramus tubarius from the anastomosis with the arteria ovarica also secures the vascular supply of the fallopian tube. However, when salpingectomy is performed concomitant to hysterectomy, the ramus tubarius will be removed. Accordingly, all the blood passing through the ligamentum infundibulo pelvicum will now become available to the ovaries. Blood circulation through the ovaries should thus remain unaffected or even increase when hysterectomy is combined with salpingectomy.

The few available studies support the hypothesis that removal of both uterus and fallopian tubes causes a redistribution of the blood flow in favor of the ovaries. Moreover, hormone production by the ovaries was also found to be unaffected even months after the intervention (2, 3).

A similar situation occurs when salpingectomy is performed during sterilization. In this case, however, ovarian blood supply does not only rely on the arteria ovarica, the anastomosis with the arteria uterina is also still available. Accordingly, a reduced vascular supply of the ovaries after salpingectomy could only be caused by poor surgical technique, for example, by preparation or coagulation deep inside the tubal-ovarian ligament. Still, the risk of extensively coagulating the tubal-ovarian ligament also exists when the fallopian tubes are retained but coagulated for sterilization. In fact, a properly performed salpingectomy should not have any negative consequences for the patient provided that the release from the mesosalpinx is performed as close as possible to the fallopian tube and in small steps.

Moreover, fallopian tubes that are retained after hysterectomy or sterilization are not only devoid of any known physiological function. They can also give rise to subsequent tubal pathology like hydrosalpinx and most likely to ovarian cancer (4, 5). Considering that the improved vascular situation after salpingectomy also argues against the (theoretically conceivable) induction of a premature “surgical” menopause, the article by Findley et al. (1) further supports the concept that removal of postreproductive fallopian tubes during hysterectomy or sterilization is in the best interest of the patient.

Johannes Dietl, M.D., Jörg Wischhusen
University of Würzburg Medical School
Department of Obstetrics and Gynecology
Würzburg, Germany

References

1. Findley AD, Siedhoff MT, Hobbs KA, Steege JF, Carey ET, McCall CA, Steiner AZ. Short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve: A pilot randomized controlled trial. Fertil Steril 2013; xx: xx.

2. Sezik M, Ozkaya O, Demir F, Sezik HT, Kaya H. Total salpingectomy during abdominal hysterectomy: effects on ovarian reserve and ovarian stromal blood flow. J Obstet Gynecol Res 2007; 33: 863-9.

3. Petri Nahás EA, Pontes A, Nahas-Neto J, Borges VT, Dias R, Traiman P.
Effect of total abdominal hysterectomy on ovarian blood supply in women of reproductive age. J Ultrasound Med 2005; 24: 169-74.

4. Dietl J, Wischhusen J, Häusler SFM. The post-reproductive fallopian tube: Better removed? Hum Reprod 2011; 26: 2918-24.

5. Gilks CB, Miller D. Opportunistic salpingectomy for women at low risk for development of ovarian carcinoma: The time has come. Gyneco Oncol 2013; 129: 443-4.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2013.12.020

The authors respond:

Drs. Dietl and Wischhusen call into question the theory that performing salpingectomy during hysterectomy or tubal sterilization may lead to decreased ovarian reserve. Their observation is based on the fact that the ovary receives its blood supply from two main sources—the ovarian artery and the uterine artery, and that the shared vascular anastomoses between the ovary and fallopian tube that are sacrificed during salpingectomy are not the actual source of blood to the ovary.

While is has been shown that hysterectomy itself may lead to decreased ovarian reserve and possible premature ovarian failure(1), the available evidence regarding salpingectomy at the time of hysterectomy suggests that removal of the fallopian tubes does not result in any additional reduction in ovarian reserve (2-4). While these studies have had small numbers of patients and none have evaluated ovarian reserve on a long-term basis, data from infertility patients undergoing salpingectomy prior to IVF treatment have yielded similar results (5). These findings lend support to the anatomical concepts described by Drs. Dietl and Wischhusen.

The authors of this letter to the editor also mention that surgical technique plays an important role in maintaining adequate blood supply to the ovary, and this is a very significant point. It is imperative to keep in mind that when performing a salpingectomy one must take care to avoid damage to the ovarian vessels. This is achieved by staying in close proximity to the fallopian tube during excision, no matter which source of electrosurgery is chosen to perform the procedure, in order to avoid direct trauma or thermal injury to the ovarian vessels.

It is our opinion that salpingectomy, when properly performed during hysterectomy, is unlikely to cause any deleterious effects on ovarian reserve beyond the hysterectomy itself. What remains unknown, however, is whether this intervention will have any meaningful impact on the incidence of high-grade pelvic serous cancers. Because of the potential impact on cancer prevention, salpingectomy during hysterectomy or tubal sterilization will continue to remain an important focus of research.

Austin D. Findley, M.D., M.S.C.R.
Department of Obstetrics and Gynecology, Wright-Patterson Medical Center
Wright-Patterson Air Force Base, Ohio

References

1. Moorman PG, Myers ER, Schildkraut JM, Iversen ES, Wang F, Warren N. Effect of hysterectomy with ovarian preservation on ovarian function. Obstet Gynecol 2011;118:1271-9.

2. Findley AD, Siedhoff MT, Hobbs KA, Steege JF, Carey ET, McCall CA, et al. Short-term effects of salpingectomy during laparoscopic hysterectomy on ovarian reserve: a pilot randomized controlled trial. Fertil Steril 2013;100:1704-8.

3. Morelli M, Venturella R, Mocciaro R, Di Cello A, Rania E, Lico D, et al. Prophylactic salpingectomy in premenopausal low-risk women for ovarian cancer: primum non nocere. Gynecol Oncol 2013;129:448-51.

4. Sezik M, Ozkaya O, Demir F, Sezik HT, Kaya H. Total salpingectomy during abdominal hysterectomy: effects on ovarian reserve and ovarian stromal blood flow. J Obstet Gynaecol Res 2007;33:863-9.

5. Almog B, Wagman I, Bibi G, Raz Y, Azem F, Groutz A, et al. Effects of salpingectomy on ovarian response in controlled ovarian hyperstimulation for in vitro fertilization: a reappraisal. Fertil Steril 2011;95:2474-6.

Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2013.12.021

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