In the United Kingdom, female sterilisation will not be available on non-medical grounds unless the woman has had at least 12 months’ trial using Mirena or long acting etonogestrel-releasing implant (such as Nexplanon) and found it unsuitable (in line with the UK Medical Eligibility Criteria for Contraceptive Use 2009). If a woman has a personal history of breast or other hormonal cancer and wish to avoid all hormonal methods then a copper intrauterine device should be suggested for the trial period. Female sterilisation is funded by the Clinical Commissioning Groups (CCG) if the criteria is met. The Faculty of Sexual and Reproductive Healthcare guidance for female sterilisation is restricted to tubal occlusion only whether it can be performed at the time of caesarean section or at an interval after pregnancy using modified Pomeroy or Filshie clips [20]. Therefore, sterilisation with salpingectomy is not widely used in the United Kingdom due to the guidance from the local professional bodies that we have adopted.

The available evidence so far suggests that opportunistic salpingectomy is safe and likely to be effective and cost-effective as an ovarian cancer prevention strategy. However, there has been skepticism about the safety and absolute benefit of this practice [21]. There are no long-term studies confirming that salpingectomy does not compromise ovarian function. Opportunistic salpingectomy does not appear to affect ovarian function in the short term. Morelli et al. demonstrated no significant difference in pre- and postoperative levels of anti-Mullerian hormone (AMH), follicle stimulating hormone (FSH), antral follicle count, mean ovarian diameter, and peak systolic velocity, as measures of ovarian function assessed 3 months after hysterectomy [22].  On the other hand, Ye et al. reported that bilateral salpingectomy was associated in decreased AMH and increased FSH levels in women seeking IVF, compared to those not having tubal surgery [23]. It is suggested that salpingectomy undermines ovarian reserve, although there was no difference in the total number of follicles and oocytes retrieved from both ovaries. These outcomes will remain unknown for at least another one or two decades. As sterilisation procedures are generally performed on a younger population, any detrimental effect on ovarian function could have a greater negative impact. The absolute benefit from opportunistic salpingectomy is estimated at a number needed to treat (NNT) of 273 to prevent one case of ovarian cancer during hysterectomy, and NNT of 366 for surgical sterilisation (instead of tubal ligation). While these NNT estimates seem high, they are comparable to the NNT of 324 to prevent one case of cervical cancer with human papilloma virus vaccination [24], which reflect the relatively low incidence of ovarian and cervical cancers in our population.

There are several small studies supporting the feasibility of bilateral salpingectomy at caesarean section, but larger studies are required to confirm this finding, as common-sense-based medicine would suggest an increased risk of complications due to the engorged adnexa in the peripartum period. The downside in changing from a tubal sterilisation to an OBS, could mean adding additional port(s) (three ports instead of two) and it could also include the use of another surgical instrument with its own energy and complication rate. When OBS is considered in patients for sterilisation, we need to underline the definite character of this technique as 2-5% of patients will show regret later in life, especially in younger patients (younger than 40).

In a study looking at immediate and short-term complications and surgical duration among women having laparoscopic salpingectomy (n=81) or tubal occlusion (n=68) for female sterilisation there was no difference in complication rate, but the average surgical time was 6 min longer for salpingectomy compared to occlusive methods (44±13 min versus 38±15 min, respectively, p=0.018) [25]. There is no doubt thatperforming salpingectomy to the fallopian tubes that are adherent to other pelvic structures could increase operation time and the complication rate. Laparoscopic sterilisation with tubal occlusion is classified as basic laparoscopic surgery training in the RCOG training matrix for the trainees in the United Kingdom. If we are replacing tubal occlusion with salpingectomy, a higher level of training level is required and the trainees will not be able to get this laparoscopic or open salpingectomy competency signed off until they become senior trainees. This will have an impact in the training programme.