Salivary Progesterone Concentrations Tubal Sterilization

SUSANNA SUMIALA, MD, JUHANI JUHANI M;IENPk$ MD TUOMINEN,

After
MD, AND

PhLic, ILPO HUHTANIEMI,

Objective: To find out if ovarian endocrine function is hampered by laparoscopic tubal sterilization. Methods: Salivary progesterone levels were measured in 55 women undergoing a laparoscopic tubal sterilization with Hulka or Filshie clips. The participants were 31-43 years old (mean 37) and were menstruating regularly. The saliva was collected every morning during three menstrual cycles: on the cycle preceding sterilization, and 3 and 12 months after the procedure. Salivary progesterone levels were determined by a radioimmunoassay. ResuIts: Total progesterone secreted in the luteal phase declined slowly after the sterilization, resulting in the Iowest values 1 year after the procedure (1780 f 807 versus 2431 f 1187 pmol/L before surgery, P = .OOl). The luteal peak progesterone values were lowest 3 months after sterilization (277 f 137 pmol/L). Although the peak progesterone secretion seemed to have started to recover at 12 months (318 f 171 pmol/L), it was still significantly less than before surgery (378 -C 150 pmol& P = .015). The length of the entire menstrual cycle and the lengths of the follicular and luteal phases were not affected. Conclusion: Although the menstrual pattern was not affected, laparoscopic tubal sterilization caused measureable changes in the luteal function. However, these changes may be temporary in nature. (Obstet Gynecol 1996;88:792-6)

pulsatile nature of progesterone secretion,,ll resulting in a wide daily fluctuation in serum progesterone levels. Measuring a few serum progesterone levels may not be accurate enough to evaluate the function of the corpus luteum. I2 A daily sampling over the entire luteal phase would circumvent this problem by offering a number of observation points large enough to allow a pattern of progesterone secretion to be seen. However, a daily blood sampling is impractical and inconvenient to the patient. Following corpus luteum function over many cycles by daily measurement of the salivary progesterone level is convenient. The collection of the samplesis easy and the analysis of progesterone concentrations is reliable. Salivary progesterone concentrations correlate well with those of serum.13-17 Evaluation of the magnitude and length of the luteal phase progesterone secretion also is possible. The aim of this study was to evaluate prospectively the effects of tubal sterilization on corpus luteum function by using salivary progesterone measurements.

Materials and Methods

Worldwide, tubal sterilization has become one of the most prevalent methods of contraception. The development of laparoscopic techniques has made it safe and easy to perform. However, there has been concern that the tubal occlusion may disturb ovarian function, resulting in an altered secretion of ovarian hormones. Several studieslm4have implied that serum progesterone levels decline after sterilization, although more recent studies5-9failed to confirm those findings. The controversy can be explained at least partially by the
From the Departments of Obstetrics
and Physiology, University Obstetrics and Gynecology, Finland. of Turku, Tampere and Gynecology, Biostatistics, Turku; and the Department of University Hospital, Tampere,

Fifty-five women requesting surgical interval sterilization at the Department of Obstetrics and Gynecology of the Turku University Central Hospital and fulfilling the eligibility criteria volunteered for the study. The participants had to be healthy, less than 44 years of age, regularly menstruating, and have parity of at least one; they were not allowed to use any hormonal contraception for at least 2 months before the sample collection. Meanwhile, the women were advised to use barrier methods for contraception unless they had intrauterine copper-releasing devices (16 women). The recruitment period was from January 1990 to April 1992. The mean age of the volunteers was 37 years (range 31-43), and the mean cycle length was 27 days (range 22-31). All patients gave verbal informed consent. The steriliza-

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tions were performed laparoscopically with Hulka clips (n = 25) or Filshie clips (n = 30). General anesthesia was used in all cases. The women collected saliva every morning during three complete menstrual cycles, starting on the first day of menstrual bleeding. The cycles studied were the cycle immediately before the sterilization (cycle l), one cycle at 3 months (cycle 2) after the procedure, and one cycle at 12 months (cycle 3) after the procedure. Only the complete or near-complete cycles (data missing from no more than 4 nonconsecutive days) were accepted for the analysis. The patients collected saliva (at least 2 mL) every morning into a plastic test tube without stimulation before having breakfast or brushing their teeth. The samples were stored in home freezers (-17 to -20C). All samples of a single collection period were delivered at the same time to the laboratory and stored at -20C until analyzed. The progesterone concentrations in the salivary samples were measured by a radioimmunoassay (RIA) method described previously? In brief, after thawing and centrifugation, 500 PL of the sample supernatants were transferred in duplicate into glass tubes and extracted with 2.5 mL of freshly distilled diethyl ether. The extracts were dried and reconstituted in 100 PL of assay buffer, then 100 FL each of the rz51-iodoprogesterone tracer and the antiserum were added. The standards, in dilutions of 31-1000 pmol/L, were handled in the same way as the unknown samples. The tubes were incubated overnight at 4C. On the next day, bound and free hormone were separated by the use of polyethylene glycol. The pellets were counted in a gamma spectrometer (1260 Multigamma II; LKB Wallac, Turku, Finland) connected to an on-line computer that gave progesterone concentrations in pmol/L. The sensitivity of the RIA method was 40 pmol/L, and the intra-assay and inter-assay coefficients of variation were 10.3 and 15%, respectively. A daily menstrual salivary progesterone profile was constructed for 144 cycles (55 cycles before the sterilization, 54 cycles at 3 months, and 35 cycles 1 year after the sterilization). One participant did not deliver the samples at 3 months, and 20 did not do so at 12 months. For 103 cycles, the measurements were started on the first day of the period. For 41 cycles they were not started until the tenth day, because we found that ovulation did not happen before the 11th day. The luteal phase was defined to start on the day (day 0) when the salivary progesterone level rose for the first time above 100 pmol/L and stayed elevated for at least 2 following days. Several indices were calculated from the profiles. Starting from day 0, the cumulative sum of daily salivary progesterone concentrations was measured un-

til the end of the cycle. The time (T95) during which 95% of the total cumulative luteal-phase progesterone (C95) was secreted was calculated. Logarithmic transformation was used for C95, because its distribution was skewed. The means between three cycles were compared by unbalanced repeated measures analysis of variance with unstructured covariance mat&l Analysis of variance takes into account that any same woman contributes three cycles at most, and that the number of cycles per woman may vary so the data are unbalanced. Essential variation in repeated-measures analysis of variance is the within-subject variation, ie, the variation between two consecutive measurements instead of between-subject variation. Analysis of variance controls type I error and allows us to use all available data as well as take into account the correlation (covariance) structure. When analysis of variance revealed statistically significant variation between cycles, the analysis was continued by doing pairwise comparisons between cycles by linear contrasts of the analysis of variance model. The computations were done using program 5V of the BMDP software package (BMDP Statistical Software Inc., Los Angeles, CA).

Results
There were no statistically significant changes in the average length of the menstrual cycle or in the length of follicular and luteal phases and T95 before and after the procedure. The number of days in the entire menstrual cycle was (mean + standard deviation) 26 f 2.4 before the operation and 26.6 + 3.0 and 26.1 -+ 2.4 3 and 12 months after the surgery, respectively. The length of the follicular phase was 16 2 3.2, 14.7 2 3.7, and 15.6 +- 2.4 days. The corresponding figures for the luteal phase were 10.8 + 3.0, 12.1 + 3.0, and 10.6 t 2.6 days. Altogether, there were ten cycles with no luteal phase, indicating an ovulation. Two women had an anovulatory cycle 1, seven patients had an anovulatory cycle 2, and one patient an anovulatory cycle 3. No one had more than one anovulatory cycle. The difference in the number of anovulatory cycles was not statistically significant. The total progesterone secreted by the ovaries decreased significantly after the sterilization (analysis of variance, P < .OOl) (Figure 1). The change already occurred between cycles 1 and 2 (P = .035), but it was even greater between cycles 1 and 3 (P < .OOl). The difference between cycles 2 and 3 was not statistically significant (P = .OSl). After the logarithmic transformation of C95, the change was still significant at a level of P = .002 (analysis of variance) (Figure 2). The decrease

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Figure 1. Mean cumulative daily salivary progesterone trations (pmol/L 2 standard tion [SD]) in luteal phase sterilization (cycle l), then 2) and 12 months (cycle sterilization.

sum of concendeviabefore 3 (cycle 3) after

examination

in log C95 occurred slowly between cycles 1 and 3 (P < .OOl), because between cycles 1 and 2 (P = .074) and 2 and 3 (P = .122) there were no statistically significant changes. The luteal peak progesterone concentration also changed significantly (analysis of variance, P < .OOl) (Figure 3). The highest luteal peak progesterone values were measured in cycle 1 and the lowest in cycle 2 (P < .OOl), but in cycle 3, the peak values were still lower than in cycle 1 (P = ,015). Between cycles 2 and 3 there was no significant change (P = .320).

Discussion
Several investigators have reported menstrual and hormonal disturbances after tubal sterilization.2-4f20-22 Alterations in the ovarian blood flow caused by the tubal ligation may lead to ovarian dysfunction; however, more traumatic procedures, like the Pomeroy method or diathermy, may affect the utero-ovarian circulation more than application of the Hulka or Filshie clips. However, the clips may damage the vessel walls if not applied with extreme care. Other studies6~*~23~24 have

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3 2 +I P 0 B 1
Figure 2. Mean logarithmic transformation of daily salivary progesterone concentrations (log C95 i standard deviation [SD]) in luteal phase before sterilization (cycle l), then 3 (cycle 2) and 12 months (cycle 3) after sterilization. C95 = 95% of the total cumulative luteal-phase progesterone.

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Figure 3. Mean luteal peak progesterone values (pmol/L f standard deviation [SD]) before sterilization (cycle l), then 3 (cycle 2) and 12 months (cycle 3) after sterilization.

examination

failed to confirm differences between the outcome of various sterilization techniques. Previously, we have demonstrated using color Doppler sonography that sterilization with clips may increase the local vascular resistance.25 We have previously applied salivary progesterone determinations to evaluate effects of hysterectomy on ovarian functionz6 The present results indicate that tubal occlusion with the Hulka or Filshie clips affects ovarian function, as assessed by measuring the salivary progesterone levels immediately before and during the first post-sterilization year. The total cumulative sum of daily salivary progesterone concentrations and the calculated log C95 were highest before sterilization. After the procedure, the concentrations declined slowly, with the lowest values noted during the last cycle, or 1 year after the procedure. No strong conclusions can be drawn about the reversibility of the defect. This would have required a longer follow-up period, in which case the deleterious effect of aging would have been difficult to exclude. Our hysterectomy study26 implied that the adverse effect of surgery on ovarian function is only temporary. Likewise, in the present study, the luteal peak progesterone values seemed to start returning to the pre-sterilization level during the follow-up period. The values were lowest 3 months after the procedure, although the difference between the values before the procedure and 1 year after it was still statistically significant (P = .015). Because luteal peak progesterone values of 300-800 pmol / L can be regarded as norma1,7*27 the values 3 months after sterilization (277 +- 137 pmol/L) may be physiologically significant.

Interestingly, most of the women had normal cyclic ovarian function after the sterilization. The length of the menstrual cycles and the lengths of the foIlicular and luteal phases were not affected. Likewise, there was no statistically significant change in T95. It may be that the observed changes in the ovarian function were too subtle to be reflected in the menstrual pattern. However, in accordance with the luteal peak progesterone values, more cycles tended to be anovulatory 3 months after the sterilization, although the difference was not statistically significant. Of course, it is possible that women with irregular or altered menstrual cycles may have been more likely to continue participation compared with the menstrual patterns of those who dropped out.

References
1. Radwanska E, Berger GS, Hammond J. Luteal deficiency among women with normal menstrual cycles, requesting reversal of tubal sterilization. Obstet Gynecol 1979;54:189-92. E, Headley SK, Dmowski P. Evaluation of ovarian 2. Radwanska function after tubal sterilization. J Reprod Med 1982;27:376-84. 3. Donnez J, Wauters M, Thomas K. Luteal function after tubal sterihzation. Am J Obstet Gynecol 1981;57:65-8. 4. Hargrove JT, Abraham GE. Endocrine profile of patients with post-tubal-ligation syndrome. J Reprod Med 1981;26:359-62. 5. Alvarez F, Faundes A, Brache V, Tejada AS, Segal S. Prospective study of the pituitary-ovarian function after tubal sterilization by the Pomeroy or Uchida techniques. Fertil Steril 1989;51:604-8. 6. Rivera R, Gaitan JR, Ruiz R, Hurley DP, Arenas M, Flores C, et al. Menstrual patterns and progesterone circulating levels following different procedures of tubal occlusion. Contraception 1989;40:15769. 7. Helm

G, Sjiiberg

N-O.

Progesterone

levels before

and after lapa-

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8.

9.

10. 11.

12. 13.

14.

15. 16.

17.

18.

19. 20.

21.

roscopic tubal sterilization using endotherm coagulation. Acta Obstet Gynecol Stand 1983;62:63-6. Carson SL, Levinson CJ, Batzer FR, Otis C. Hormonal levels following sterilization and hysterectomy. J Reprod Med 1981;26: 363-70. Thranov I, Hertz JB, Kjer JJ, Andresen A, Micic S, Nielsen J, et al. Hormonal and menstrual changes after laparoscopic sterilization by Falope-rings or Filshie-clips. Fertil Steril 1992;57:7515. Filicoti M, Butler JP, Crowley WF. Neuroendocrine regulation of the corpus luteum in the human. J Clin Invest 1984;73:1638-47. So&s MR, Clifton DK, Steiner RA, Cohen NL, Bremner WJ. The corpus luteum: Determinants of progesterone secretion in the normal menstrual cycle. Obstet Gynecol 1988;71:659-66. McNeely MJ, Soules MR. The diagnosis of luteal phase deficiency: A critical review. Fertil Steril 1988;50:1-15. Walker S, Mustafa A, Walker RF, Riad-Fahmy D. The role of salivary progesterone in studies of infertile women. Br J Obstet Gynaeco11981;88:1009-15. Zorn JR, McDonough PG, Nessman C, Janssens Y, Cedard L. Salivary progesterone as an index of the luteal function. Fertil Steril 1984;41:248-53. Riad-Fahmy D, Read GF, Walker RF, Griffits K. Steroids in saliva for assessing endocrine function. Endocrinol Rev 1982;3:367-95. Riad-Fahmy D, Read GF, Walker RF. Salivary steroid assays for assessing variation in endocrine activity. J Steroid Biochem 1983; 19:265-72. Lenton EA, Gelsthorp CH, Harper R. Measurement of progesterone in saliva: Assessment of the normal fertile range using spontaneous conception cycles. Clin Endocrinol 1988;28:637-46. Vuorento T, Lahti A, Hovatta 0, Huhtaniemi I. Daily measurements of salivary progesterone reveal a high rate of anovulation in healthy students. Stand J Clin Lab Invest 1989;49:395-401. Crowder MJ, Hand DJ. Analysis of repeated measures. London, New York, Tokyo, Melbourne, Madras: Chapman and Hall, 1990. Shain RN, Miller WB, Mitchell GW, Holden AEC, Rosenthal M. Menstrual pattern change 1 year after sterilization: Results of a controlled, prospective study. Fertil Steril 1989;52:192-203. Shy KK, Stergachis A, Grothaus LG, Wagner EH, Hecht J, Anderson G. Tubal sterilization and risk of subsequent hospital admission for menstrual disorders. Am J Obstet Gynecol1992;166:1698706.

22. Cattanach JF, Milne BJ. Post-tubal sterilization problems correlated with ovarian steroidogenesis. Contraception 1988;38:541-51. 23. Sahwi S, Toppozada M, Kamel M, Anwar MY, Ismail AAA. Changes in menstrual blood loss after four methods of female tubal sterilization. Contraception 1989;40:387-98. 24. DeStefano F, Huezo CM, Peterson HB, Rubin GL, Layde PM, Ory HW. Menstrual changes after tubal sterilization. Obstet Gynecol 1983;62:673-81. 25. Sumiala S, Pirhonen J, Tuominen J, Mlenpll J. Increased uterine and ovarian vascular resistance following Filshie clip sterilization: Preliminary findings obtained with color Doppler ultrasonography. J Clin Ultrasound 1995;23:511-6. 26. Vuorento T, MBenpHT J, Huhtaniemi I. Follow-up of ovarian endocrine function in premenopausal women after hysterectomy by daily measurements of salivary progesterone. Clin Endocrinol 1992;36:505-10. 27. Li TC, Lenton EA, Dockery I, Rogers AW, Cooke ID. The relation between daily salivary progesterone profile and endometrial development in the luteal phase of fertile and infertile women. Br J Obstet Gynaecol 1989;96:445-53.

Address reprint requests to: Susanna Sumiala, MD Department of Obstetrics and Gynecology University Central Hospital 4-8 Kiinamylfynkutu FIN-20520 Turku Finland

Received March 18, 1996. Received in revised form June Accepted July 7, 1996.

24, 1996.

Copyright 0 1996 by The American College of Obstetricians Gynecologists. Published by Elsevier Science Inc.

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