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Sir,

We read with interest the recent study by Povedano et al.,1,2 and accompanying commentary by Clark, regarding the outcome of the Essure® sterilisation system. The authors of the study should be congratulated for their work, which clearly shows that outpatient hysteroscopic sterilisation is an effective technique associated with low postoperative morbidity. We would, however, like to highlight an important aspect omitted from Mr Clark’s commentary on the future direction of female sterilisation, namely that of the mounting evidence that high-grade serous ‘ovarian’ cancers are likely to be tubal in origin. An inverse relationship between ovarian cancer and tubal ligation was reported 20 years ago,3 and over the past decade there is increasing evidence identifying tubal epithelium as the likely site of origin of the most common and lethal subtype of ovarian cancer, high-grade serous carcinoma.4 The survival from ovarian cancer has altered little over the past three decades, despite the introduction of many new chemotherapeutic agents, refinement of surgical techniques and concerted efforts for early diagnosis. Screening, either in general or high-risk populations, has yet to be shown to be effective,5 and as such primary prevention must remain our key aim. Indeed, in British Columbia a more radical approach is being taken with a campaign for bilateral salpingectomy to be performed as the method of choice of sterilization, rather than tubal ligation, with the aim of reducing the incidence of high-grade serous carcinoma by removing the site from which most ovarian cancers originate.6 Although we accept that this approach is controversial and would be associated with greater operative morbidity, as compared with an outpatient hysteroscopic sterilisation, we feel that consigning the laparoscopic sterilisation to history in favour of a hysteroscopic approach because of the short-term advantages may have unforeseen long-term consequences. In women’s health it is important that changes in practice are not taken in isolation without considering possible future implications, and we would advise that long-term follow up data on all women undergoing this new sterilisation procedure would be essential so that any effect on the incidence of ovarian cancer can be detected at the earliest opportunity.

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