#sterilization method

"The authors report a case of pregnancy of the uterine horn occurring after total salpingectomy." This is the first case we could find.

Case 2 - March 2005 - Nonviable (resolved spontaneously)

"Spontaneous pregnancy after bilateral salpingectomy." Fertil Steril. 2005 Mar;83(3):767-8. Bollapragada SS, Bandyopadhyay S, Serle E, Baird C.

A case report "[to] report a rare case of spontaneous pregnancy following bilateral salpingectomy" at a "[m]aternity unit at a district general hospital in the United Kingdom", in which a "healthy 38-year-old woman with a history of bilateral salpingectomy" was "diagnosed with a noncontinuing pregnancy that resolved spontaneously" - i.e. the pregnancy was nonviable and resolved itself. (The authors also note: "A MEDLINE search revealed that this is the first reported case of spontaneous pregnancy following bilateral salpingectomy in the English-language literature and possibly only the second in world literature." The full text of the above article from January 1994 is in French.)

Case 3 - 2007 - Nonviable (treated surgically; patient recovered normally)

"Tubal ectopic pregnancy following bilateral salphingectomies." Singapore Med .1 2007; 48(8):787-788. Joosoph J, Siow A. (PDF)

"A 31-year-old woman with one previous vaginal birth, one caesarean section and two previous ectopic pregnancies", who had previously undergone bilateral salpingectomies to treat her ectopic pregnancies, was found to be pregnant by a urine test. However, her "uterine cavity was empty". The pregnancy had occurred in a tiny remnant of one of her fallopian tubes that was not removed (possibly could not have been removed) during her prior surgeries. The patient underwent surgery to remove the mass and "recovered uneventfully after the surgery and was discharged the following day."

Case 4 - April 2008 - Viable (patient decided to terminate the pregnancy)

"Pregnancy following bilateral salpingectomy." Ugeskr Laeger. 2008 Apr 21;170(17):1437-8. Bang A.

"This report presents a rare case of spontaneous pregnancy following bilateral salpingectomy. A woman with a history of bilateral salpingectomy was admitted to hospital because of abdominal pain and positive urine HCG. Surprisingly, ultrasound confirmed a live intrauterine fetus. The pregnancy was unwanted, and the woman decided to terminate the pregnancy."

Case 5 - September 2014 - Nonviable (treated surgically; patient recovered normally)

"An Ovarian Pregnancy in a Patient with a History of Bilateral Salpingectomies: A Rare Case." Case Reports in Obstetrics and Gynecology. Volume 2015, Article ID 740376, 3 pages. Sadia Khandaker, Pranav Chitkara, Eric Cochran, and Jed Cutler.

"The patient is a 32-year-old [who had had 5 pregnancies in the past] [...] The patient had informed the emergency staff that she could not be pregnant, as she had both tubes previously removed. Despite this, a urine pregnancy test was ordered as part of the emergency room's routine lab work, and it was found to be positive. [...]

"The impression was a ruptured ectopic pregnancy and surgical intervention was recommended. The patient consented and laparoscopy was performed. Upon entry into the abdomen, 1000 milliliters of clotted and liquid blood was found. The stumps of both fallopian tubes were present [...]"

As explained in our full article on bilateral salpingectomy, it is not possible to remove the stumps of the tubes because these sections travel through the muscle of the uterus. For this reason, it is possible (through very rare) for a pregnancy to occur within these stumps. In this case, Fig. 2 within the article "confirms the diagnosis of an ovarian pregnancy."

Case 6 - May 2019 - Viable (live birth)

"Missouri woman gets pregnant after fallopian tubes removed" - The Kansas City Star, published May 27, 2019 by Andy Marso.

Unlike the cases above, this is not a medical paper. However, we wanted to publish the article anyway, so that you can read it and decide for yourself.

The article is credible in that both the patient and the author get several key details right, which these sorts of articles usually don't - for example: the difference between partial bilateral salpingectomy for tubal ligation and complete bilateral salpingectomy (which this patient underwent); the ovarian cancer risk reduction; the benefits of bilateral salpingectomy; the prior case reports of post-bilateral-salpingectomy pregnancies in the medical literature; and other details.

At the least, it seems that the patient really did have a bilateral salpingectomy (as opposed to a tubal ligation or a unilateral salpingectomy):

"Kough's medical records from Virginia, which she provided to The Star, indicate that the surgery was a success. They include not only the surgeon's notes but also a report from a pathologist who confirmed seeing Kough's fallopian tubes, outside her body, after they were removed.

"Still, Kough said that when Benjamin was born via planned cesarean section, the surgeons double-checked.

"'They said, 'No there's nothing there. The surgeon did everything correctly. There's no tubes,' Kough said.'"

The article itself hypothesizes that the stumps may not have been sealed properly:

A 2007 article published in the Singapore Medical Journal theorized that in some women who have both tubes removed [...] the area where the fallopian tube previously connected to the uterus may not completely close over. In very rare cases, an egg might travel through the space between the ovary and the uterus [...] and reach that opening [...]

This would nevertheless be considered a sterilization failure from a medical perspective.

Again, this is not a medical paper, and we will make an update to this page if this case is ever published in a medical journal. This is still an extremely recent case.

In addition, we each know several users who are in similar positions and who are now seeking bilateral salpingectomies as well.

What follows is written by D unless otherwise indicated:

At the time I had my tubal ligation 7 years ago, I tried to get a bilateral salpingectomy instead, but I wasn't able to. Standards of care were different then and my doctor said she couldn't remove my tubes without medical reasons. It was uncommon at that time for doctors to do salpingectomies for sterilization alone; I don't know anyone personally who had a salpingectomy around that time for the purpose of sterilization. Starting in Jan. 2015, standards of care have changed and the majority of sterilization procedures - about 80% of those we've seen in childfree and sterilization communities online - are salpingectomies.

Problem

Most of the literature only recommends opportunistic salpingectomy, but the opportunity for an opportunistic salpingectomy has passed.

I could get a bilateral salpingectomy instead of a tubal ligation if I were having it done today, but as it stands, I need to convince my doctor (or someone else) to do a whole second surgery on me just to remove my tubes, not instead of ligation.

H adds: The reason I used to convince my gyno (who did my tubal originally) to do the bilat. salp. is that I have family history of ovarian cancer. She wasn't enthusiastic about it because it's a second unnecessary surgery and there are always risks associated with surgery, but she was ok with it.

Why?

(1) Reduce my risk of ovarian cancer

The American College of Obstetricians and Gynecologists recommends salpingectomy at the time of tubal ligation. Recent research suggests the tubes are the origin of the majority of ovarian cancers and that removal of the tubes reduces ovarian cancer risk

Many Ovarian Cancers May Start in Fallopian Tubes - National Cancer Institute

2015 study: “Salpingectomy […] is associated with reduced risk of ovarian cancer. […] a substantial fraction of ovarian cancer arises in the fallopian tube. Our results suggest that removal of the fallopian tubes […] is an effective measure to reduce ovarian cancer risk in the general population.”

2016 study: "significant decrease in the risk of [ovarian cancer] occurrence in the patients who underwent [bilateral salpingectomy] relative to the controls"

TL also reduces risk of ovarian cancer, but salpingectomy reduces it more because it removes the fimbriated part of the tube. Not all TL methods reduce risk of ovarian cancer to the same degree.

A relative on my mom's side was diagnosed with ovarian cancer in 2017, so I now have a confirmed family history of ovarian cancer (H adds: I have two relatives on my mom's side diagnosed with ovarian cancer in the last five years.)

According to the American Cancer Society, the average woman has about a 1% (1 in 108) lifetime probability of dying from ovarian cancer, and a 1 in 79 lifetime probability of being diagnosed with ovarian cancer.

The odds increase with total number of lifetime ovulatory cycles, so you're at somewhat higher risk if you've never been pregnant, especially if you've also never used hormonal birth control.

Only 20% of those diagnosed with ovarian cancer have either BRCA mutation (H adds: I've seen the numbers lower, like 10-15%.)

Ovarian cancer is extremely hard to screen for or detect early, and it's extremely deadly if you do develop it

Most have advanced stage disease at the time of diagnosis

My mom recently underwent genetic testing and was negative for the mutations she was tested for - BRCA 1 & 2. There's no cancer on my dad's side, which means I likely don't have the mutations either. That brings my lifetime risk of ovarian cancer down since 20% of cases have BRCA mutation. 1 in 108 => 0.8 in 108 = 1 in 135 lifetimes

Preliminary research suggests bilateral salpingectomy (without oophorectomy) reduces ovarian cancer risk by at least 30%, up to 70 or 80%. Combined with the above, that would take my lifetime risk of dying from ovarian cancer from 1 in 135 lifetimes to (1-0.7) in 135 = 0.3 in 135 = 1 in 450 lifetimes.

Thus, bilateral salpingectomy reduces my lifetime odds of dying from ovarian cancer from 1 in 135 lifetimes to 1 in 450 lifetimes. Compare to much lower risk of death during surgery

(2) Reduce the risk of tubal ectopic pregnancy, which is often life-threatening

Insurance/Costs

Once you have one sterilization procedure (under a sterilization diagnosis code) covered by insurance, you can't get another one covered as sterilization, so the bilateral salpingectomy needs to be performed for some other reason and billed accordingly.

Estimate: it will cost about $10-15K (this is highly dependent on the facility and your location in the world and even within the US) without insurance or insurance adjustments/negotiated rates, and about $4-6K with insurance adjustments/negotiated rates. The exact patient responsibility depends on the specific insurance plan (deductible/coinsurance/copay), but it will not exceed the plan's out-of-pocket maximum.

Anecdotally, on r/childfree, ~80% of users who have been sterilized since the start of 2016 have had salpingectomies, with the majority getting 100% coverage for their salpingectomies.

This is the best-case scenario: the patient gets the ACOG-recommended procedure at no cost (free to the patient).

Here is a detailed article on the subject, published in Feb. 2016:

[...] there is no CPT code for this idea of reporting a prophylactic salpingectomy at the time of tubal ligation. CPT gives us a code for “salpingectomy” or “tubal ligation” ACOG has given the physicians/surgeons coding options for this type or clinical care and reporting.

In querying ACOG as to how should reporting/coding be done, they have stated that salpingectomy code 58700 should NEVER be used to report a sterilization procedure of any sort. The rationale behind this is that the RVU values of the salpingectomy code include the pathological changes and additional risk included in those changes that cause complications such as blocked tubes, adhesions, or even benign or neoplastic effects. Their recommendation for coding is you code as per the “intent” of doing a tubal ligation. In the request of clarity and transparency in coding and documentation, on the “notes” line of your claim form you should include a brief statement “tubal ligation via salpingectomy”.

(emphasis ours)

The "insurance fraud" myth:

Some on Reddit claim that billing a salpingectomy for sterilization as a tubal ligation via salpingectomy is insurance fraud. However, the ACOG and coding organizations (such as those referenced in the article above) disagree. Moreover, because "via salpingectomy" is included in the notes, the insurer is accurately informed of what procedure was performed.

Lastly, even cases of actual insurance fraud - such as billing a tubal ligation via salpingectomy as a tubal ligation via clips, bands, coagulation, etc. instead of via salpingectomy - can't come back to the patient. In the worst-case scenario, the physician, her office staff, or medical coders would be held responsible, not the patient. Regardless, we cannot find reference to or record of a single case being brought for a salpingectomy billed as a tubal ligation.

That said, some physicians and coders may be uncomfortable billing a salpingectomy for sterilization as a tubal ligation via salpingectomy. Not all physicians and offices bill a salpingectomy for sterilization in this manner.

Covering salpingectomy for sterilization as salpingectomy:

This is the less common option since, as discussed in the previous section, the ACOG's coding option for physicians is tubal ligation via salpingectomy. That said, this option still means the patient gets the ACOG-recommended procedure at no cost. Some insurance companies have added code 58700 under their sterilization bulletin:

With Aetna, 58700 is under their sterilization clinical bulletin as a “Salpingectomy, complete or partial, unilateral or bilateral (separate procedure)”. [...] 58661 is not there, but is under other bulletins like cancer prevention- “Laparoscopy surgical; with removal of adnexal structures (partial or total oophorectomy and / or salpingectomy”. I called Aetna today and they said that the sterilization diagnostic code does not work with the 58661 code, but does work with the 58700 code. (link)

Some other insurances, such as Blue Cross Blue Shield of Illinois, have 58661 under their sterilization bulletin. It can vary from insurer to insurer and state to state.

Not all doctors know there is a specific code that needs to be used for elective sterilizations. (...) My BCBS insurance has two codes, originally the doctor's office used code 58661 and my insurance wouldn't cover it. When they used 58700 it came up in the system as elective and my insurance covered it 100%. (The codes are for the same procedure, one is just more specific.) (link)

As another example, this user's insurer covers the 58661 code.

You can check your insurer's bulletins to see if they cover 58661 and/or 58700 under their sterilization clinical bulletin.

What about the Food and Drug Administration?

It's true that the FDA doesn't classify salpingectomy as a method of contraception or birth control (and thus as a method of sterilization). Thus, health insurers are not required to cover salpingectomy as sterilization, which also means they aren't required to cover it at 100%. (They are, with some exceptions, required to cover tubal ligation - via clips, bands, coagulation, or salpingectomy - as sterilization and at 100%.)

However, health insurance companies are still permitted to cover procedures as sterilization that the FDA doesn't classify as such. That is, even though the FDA doesn't classify salpingectomy as sterilization, health insurance companies are still legally allowed to cover it as sterilization, which ensures 100% coverage for patients.

There is at least one Redditor who claims that the FDA forbids health insurers from covering salpingectomies as sterilization - i.e. that the FDA forbids health insurers from including code 58700 or 58661 under their sterilization bulletins. This is untrue. Health insurers are not required to cover it, but they are permitted to. The FDA is not responsible for regulating health insurers directly; health insurers are regulated through legislation (including the ACA and its contraceptive coverage mandate) and court rulings, none of which forbid covering salpingectomy as sterilization.

If your insurance company doesn't cover a tubal ligation via salpingectomy as sterilization and hasn't updated their bulletins to cover 58700 or 58661 as sterilization:

This means that neither a tubal ligation via salpingectomy or a salpingectomy billed under 58700 or 58661 can be covered 100% as sterilization under the ACA. The salpingectomy under 58700 or 58661 will still be covered at pre-ACA levels (and billed accordingly). It will be subject to deductible, coinsurance, and/or copay (depending on the particular plan). The patient responsibility depends on the specific insurance plan.

Some users were unable to get 100% coverage for their salpingectomies, but they were able to get the vast majority of the cost covered. Often, they paid $250 or less for the procedure; in other cases, they paid in the $500-2000 range. In almost all cases, a tubal ligation via clips, bands, or coagulation would have been free to the patient. The decision to pay for a salpingectomy depends on (a) how much you would have to pay vs. how much you can afford and (b) how much value you place on having a salpingectomy over a tubal ligation. If you are in this position, it is very important to contact your insurance company and understand your plan so you know what to expect for patient responsibility. You can also ask your provider's office to get an estimate for you.

If you have some patient responsibility, i.e. if you have to pay:

Fighting your insurance company:

Regardless of the procedure type - tubal ligation via clips, bands, coagulation, or salpingectomy - some insurance companies won't default to 100% coverage, but will cover 100% after some prodding.

Please note that this can happen regardless of the sterilization method. Some users have had a traditional tubal ligation via clips, bands, or coagulation and have still had to fight for 100% coverage.

I just finished fighting this battle against Anthem Blue Cross. Good news is that they ended up covering everything! The National Women’s Law Center was a godsend for the appeal; I used their sterilization appeal letter template to contest the charges. It doesn’t specifically call out BLS vs TL [that is, salpingectomy vs. tubal ligation], but it got the job done. They also have a hotline you can call! (link)

Visit CoverHer.org for more information, and check out this detailed page about sterilization from the National Women’s Law Center.

Here is another user's experience of obtaining 100% coverage from her insurance company:

Figured out with my plan how much i could potentially be responsible for (i had a bilateral salpingectomy) if it wasn’t covered as a sterilization procedure and made the decision to go for it. [...] I got billed after by the hospital, called insurance (BCBS) and stated it was a sterilization procedure, which I had confirmed prior to surgery would be billed as a sterilization, and as such is covered at 100% per the ACA. Insurance let me know they’d listen to my prior call and be looking into the matter with doctor and would call me back. took a couple weeks for the final decision but they finally called and said it was covered at 100% and hospital would send out new bill. (link)

Another user's experience:

Eventually they found the one person at the hospital who had experience dealing with insurance companies and they were able to agree on a code that covered me 100%. (link)

Financial assistance & payment plans:

Another option is to discuss financial assistance and payment plans with the hospital/facility at which you will be having your surgery. You may be able to have your surgery at reduced cost, or at least have the payments distributed over a longer period of time.

Before my appointment, I went to membership services [at the hospital] and requested financial help. I didnt think I'd get it as I make just enough to comfortably get by living with my parents. They quoted the procedure at $3000 just for the surgery, not including prescriptions and stuff. But the financial all came through and I didn't pay a penny for anything. I still won't, even until July. (link)

Another user's experience:

[...] speak with the billing department of the hospital and see if they offer payment plans. When I had mine done, there was about $750 not covered (deductible and incidentals). I set up a payment plan that gave me a year without fees or interest that was much easier for me to handle than dipping into savings. (link)

Doing it at the same time as another surgery:

If you need a laparoscopy (esp. gynecologic laparoscopy) for another purpose, you may be able to undergo a sterilization procedure at the same time at minimal additional cost. A reader told us that her religious insurance wouldn't cover a tubal ligation or a salpingectomy, regardless of the method. She was able to have it done at the same time as a laparoscopy to diagnose endometriosis for only $87 additional cost.

Waiting until salpingectomies are 100% covered:

It's possible that one's insurance company would update their bulletins such that salpingectomy billed under 58700 or 58661 is covered at 100% for sterilization in the future, or that one could switch insurance companies to one that has updated their bulletins. For these reasons, one may choose to wait for a salpingectomy instead of having a tubal ligation at the present time. Of course, this is a very personal decision that depends on your satisfaction with your current birth control method(s) and how badly you want to be sterilized, among other things.

Tubal now, salpingectomy later? If I've already had a tubal ligation, can I still get a salpingectomy?

A handful of users on r/childfree and r/sterilization decided on another option: have a tubal ligation at the present time, and a salpingectomy later on once they have money saved to pay their out-of-pocket cost. The main downside is that it means two surgeries: twice the risk of infection, complications, and possible general anesthesia issues. Nevertheless, the risks are low, so it is an option.

Another downside is that once you have a sterilization procedure, insurance won't cover a second sterilization procedure on the same patient. Once you have a tubal ligation, a salpingectomy won't be covered as sterilization - it will need to be performed for a different purpose to be covered. Likely, the salpingectomy will be performed for the purpose of cancer prevention (and billed accordingly). It will be subject to deductible, coinsurance, and/or copay (depending on the particular plan). If you have a tubal ligation at the present time, you won't be able to have a salpingectomy covered at 100% in the future even if bulletins and/or insurers change.