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Opportunistic Adnexal Surgery

Opportunistic adnexal surgery — most commonly opportunistic salpingectomy (OS) — refers to removal of the fallopian tubes for primary prevention of tubo-ovarian carcinoma in women already undergoing pelvic or abdominal surgery for another indication.[1][2] The concept has rapidly become one of the most impactful preventive strategies in gynecologic oncology and is increasingly relevant to the urogynecologist who is operating in the pelvis for any reason.

Part I: Scientific rationale — the tubal hypothesis​

The foundation of opportunistic salpingectomy rests on a paradigm shift in understanding ovarian cancer pathogenesis:

Serous tubal intraepithelial carcinoma (STIC). Premalignant cells and early occult cancers have been detected in the fimbrial funnel region of the fallopian tube — but not on the ovarian surface — in risk-reducing salpingo-oophorectomy (RRSO) specimens from BRCA carriers.[3][4] STICs are detected alongside a substantial proportion of high-grade serous carcinomas; detection frequency depends on specimen sampling and is not a measure of how many cancers will develop from an individual STIC. They may be missed on routine pathological examination.[4] These findings challenged the traditional view that high-grade serous ovarian cancer (HGSOC) — the most common and lethal subtype — originates from the ovarian surface epithelium.

Key pathologic precursors distributed along the tube:[1]

  • Serous tubal intraepithelial lesions (STILs) and tubal intraepithelial lesions in transition — most frequently located in the fimbriated end.
  • Secretory cell outgrowths (SCOUTs) — distributed throughout the tube, supporting complete salpingectomy over fimbriectomy alone.

Part II: Magnitude of cancer-risk reduction​

The European Society of Gynaecological Oncology (ESGO) consensus published in JAMA (2026) synthesized the evidence:[6]

  • A 2025 meta-analysis (Tang et al.) of 1 cohort study and 4 case-control studies — bilateral salpingectomy associated with a 52% reduction in tubo-ovarian carcinoma risk (OR 0.48; 95% CI 0.33–0.69; p<0.001).[6]
  • Swedish population-based cohort (Falconer et al.) — 65% risk reduction (HR 0.35; 95% CI 0.17–0.73) after bilateral salpingectomy vs. unexposed women.[6][1]
  • Danish nationwide case-control (Madsen et al.) — 42% risk reduction (OR 0.58; 95% CI 0.36–0.95).[6]
  • Danish nationwide case-control study (Duus et al., 2023; 16,822 EOC cases, each matched to 40 controls) — risk reduction after both unilateral (OR 0.73; 95% CI 0.60–0.87) and bilateral salpingectomy (OR 0.46; 95% CI 0.31–0.67), with the protective effect increasing with time since surgery and present across most histological subtypes; the association was confined to surgery before age 50 in this study.[7]
  • Kahn et al. systematic review (2023; 158 studies) — bilateral salpingectomy could reduce tubo-ovarian carcinoma risk by up to 80% and lower ovarian-cancer mortality in the US by 15% if broadly implemented.[5]

These estimates describe observational associations with different comparators, histologies, and follow-up; they are not an assured individual lifetime reduction. A 2026 British Columbia cohort (40,527 salpingectomy; 45,296 comparator operations) found a crude serous-cancer HR 0.22 (95% CI 0.05–0.95). Few events, younger age, shorter follow-up, and incomplete confounder adjustment limit causal precision.[30]

Part III: Guideline recommendations​

SocietyYearKey recommendation
ACOG (Clinical Practice Update to CO 774)August 2026Strengthens counseling about complete bilateral salpingectomy at obstetric/gynecologic surgery and extends consideration to nongynecologic abdominopelvic operations. Discuss feasible completion when choosing the operative approach.[28]
ESGO (consensus statements)2026OS should be considered for all eligible women undergoing gynecological surgery and, when possible, non-gynecological pelvic or selected abdominal surgeries
NICE (familial/genetic risk, NG241)2024For high-risk patients, salpingectomy with delayed oophorectomy should be offered only in a clinical trial; it is not established as equivalent to RRSO.[29]
FIGO2024Firmly supports use of salpingectomy opportunistically for ovarian-cancer risk reduction
German AGO / NOGGO / AGO Austria / AGO Swiss2025Patients should be informed of benefits; Austrian AGO recommends broad use without reservation
[1][2][6][8][3]

Part IV: Surgical technique​

Complete salpingectomy principles (ACOG)[1]​

  1. Remove the tube completely from its fimbriated end up to the uterotubal junction (cornua).
  2. The interstitial portions of the tubes do not need to be removed.
  3. Any fimbrial attachments on the ovary should be cauterized or removed.
  4. Complete salpingectomy is preferred over fimbriectomy because precursors can be found throughout the tube.
  5. If complete salpingectomy cannot be performed, removing as much tube as possible (excluding the interstitial portion) still has value.

RRSO principles — for high-risk patients​

RRSO has observational evidence of cancer-mortality and survival benefit in BRCA carriers; this differs from average-risk opportunistic tube removal.[10] Follow the current specialist risk-reduction protocol, including:[29]

  • Use minimally invasive surgery when clinically appropriate.
  • Survey upper abdomen, bowel surfaces, omentum, appendix, and pelvic organs.
  • Biopsy any abnormal peritoneal findings.
  • Obtain peritoneal washings for cytology.
  • Remove both tubes and ovaries completely with appropriate specimen handling and pathological assessment; incidental cancer requires gynecologic-oncology management.
  • Minimal instrument handling to avoid traumatic exfoliation of cells.
  • Retrieve specimens in an endobag.
  • Process by SEE-FIM protocol (Sectioning and Extensively Examining the Fimbriated End).

SEE-FIM protocol​

The fimbriated end is amputated and sectioned longitudinally, while the remainder of the tube is sectioned at 2–3 mm intervals. Extensive sampling improves detection of small precursor lesions. An older US laboratory survey documented variable use of SEE-FIM; those survey percentages should not be interpreted as current universal compliance or an exact improvement in diagnostic sensitivity.[11]

Surgical completeness​

The QOS study (Maryns et al., 2026) prospectively examined 201 adnexa from 115 patients and found OS was surgically complete in ~88% of patients — residual microscopic fimbrial tissue identified in 7.4% of adnexa (12.2% of patients). No STIC lesions were detected in residual tissue. Clinical impact of remnant fimbrial tissue on cancer-risk reduction remains uncertain.[12]

Part V: Safety and perioperative outcomes​

A. At hysterectomy​

ACOG states that salpingectomy at the time of hysterectomy does not increase the risk of complications — blood transfusions, readmissions, postoperative complications, infections, or fever — compared with hysterectomy alone.[1][2] An RCT (Song et al., n = 68) found no significant differences in operative time, blood loss, or complications between hysterectomy with vs. without OS.[6]

B. At cesarean delivery​

  • An RCT (Subramaniam et al., n = 80) found OS added a mean of 15 minutes vs. tubal ligation during cesarean delivery, with no attributable adverse outcomes observed, but bilateral completion was only 27/40 (68%) versus 38/40 (95%) for ligation; this small trial was not powered to exclude uncommon harms.[32]
  • Large Canadian population-based study (Rufin et al., 2024; n = 18,184) — decreased perioperative complications with OS vs. tubal ligation (aOR 0.77; 95% CI 0.61–0.99); no difference in postoperative complications or readmissions. Slightly increased odds of filling NSAID (aOR 1.18) and opioid (aOR 1.23) prescriptions.[13]
  • US national study (Mandelbaum et al., 2021; n = 3.8 million cesarean deliveries) — by 2018, 13.2% of cesarean deliveries included bilateral salpingectomy (up from 4.6% in 2015), surpassing tubal ligation. In propensity-matched analysis, the salpingectomy group had slightly higher rates of hemorrhage (3.8% vs. 3.1%) and hysterectomy (0.8% vs. 0.4%).[14]

C. At non-gynecologic surgery​

The ESGO consensus (2026) reports perioperative-safety findings consistent for both gynecological and non-gynecological procedures, including laparoscopic and open approaches. ESGO statement 18 cautions that adding salpingectomy during vaginal hysterectomy may increase complications, although major complications remain uncommon. This procedure-specific caution does not establish that vaginal hysterectomy is generally less safe than an abdominal approach.[6]

Part VI: Impact on ovarian function​

A critical question because the fallopian tubes derive blood supply from branches of the uterine and ovarian arteries.

Short-term ovarian reserve — reassuring:

  • Systematic review and meta-analysis (Gelderblom et al., 2022; 15 studies) — no significant reduction in AMH (MD −0.07 ng/mL; 95% CI −0.18 to 0.05), AFC, E2, FSH, or LH after OS.[15]
  • Pooled analysis (Mohamed et al., 2017) — no significant AMH reduction (weighted mean difference −0.10 ng/mL; 95% CI −0.19 to 0.00; I² = 0%).[6]
  • Multiple RCTs (Asgari et al., Findley et al.) confirmed no significant difference in AMH or FSH 3 months postoperatively.[6]

Long-term menopause outcomes — mixed:

  • British Columbia cohort (Hanley et al., 2020; n = 41,413) — no increased hazard of physician visits for menopause (aHR 0.98; 95% CI 0.88–1.09) or filling HRT prescriptions after OS at hysterectomy, including age-stratified analyses with ≥5 years of follow-up.[16]
  • Swedish registry study (Collins et al.) — 33% increased risk of menopausal symptoms 1 year after hysterectomy with OS vs. hysterectomy alone (RR 1.33; 95% CI 1.04–1.69).[6]

The ESGO consensus concludes that OS does not impair short-term ovarian function and does not appear to affect age at menopause, but long-term data remain limited and a possible impact cannot be fully excluded. Premenopausal women should be counseled accordingly.[6]

Rapid adoption in the US​

Mandelbaum et al. (2020), National Inpatient Sample 2001–2015 — OS at benign hysterectomy increased from 2.4% in 2001 to 58.4% by 2015 ; the study also examined adoption after 2010, using a different time-window comparison (aOR 5.42; 95% CI 5.34–5.51).[17]

The magnitude of missed opportunity​

Moufarrij et al. (2025), JAMA Surg:[18]

  • Among 1,877 patients with HGSOC, 23.7% (445) had missed opportunities for salpingectomy — 54.2% had prior tubal ligation / hysterectomy without salpingectomy, and 45.8% had other abdominopelvic surgeries.
  • A 43.2% missed-opportunity rate for germline genetic testing and reflex risk-reducing surgery was also identified among patients with an affected first-degree relative.

Tischer et al. (2025) — nearly 60% of patients with HGSOC had ≥1 prior abdominal or pelvic surgery where OS could have been performed, often decades before diagnosis (median 30 years). Most common prior gynecologic procedure was tubal ligation (33%); most common general-surgery procedure was cholecystectomy (53.4%).[19]

Part VIII: Expanding beyond gynecologic surgery​

A frontier area is incorporation of OS into non-gynecologic abdominopelvic procedures:

  • Cholecystectomy — Matsuo et al. (2023) cost-effectiveness analysis: OS at laparoscopic cholecystectomy was cost-effective (ICER $11,162–$26,463 / QALY), preventing 30–39 ovarian-cancer cases per 5,000 women depending on age.[20] Wright et al. (2025) estimated that if OS were performed in 80% of cholecystectomies in women ≥40, 279 lifetime ovarian-cancer cases could be prevented per annual cohort.[21]
  • Broader implementation — Adjei et al. (2025) cost-effectiveness analysis of OS during 6 common abdominopelvic procedures (hysterectomy, appendectomy, cholecystectomy, gastric bypass, hernia repair, colectomy): OS was incrementally cost-saving ($2,176 per procedure) with more QALYs gained, yielding $18.78 million in healthcare savings for a single annual cohort.[22]
  • Kather et al. (2025) modeled OS at any suitable abdominal surgery in Germany — could reduce ovarian-cancer cases by 15.3% (vs. 5.5% with OS only at hysterectomy / sterilization), with an ICER of −€8,686 / QALY (cost-saving).[23]

Part IX: Salpingectomy vs. oophorectomy — key distinctions​

A critical distinction must be made between salpingectomy (tube removal only) and oophorectomy (ovary removal):

ConsiderationOpportunistic salpingectomyBilateral salpingo-oophorectomy (BSO)
Usual prevention settingAverage-risk patients who have completed childbearing and are already undergoing suitable surgeryGene-specific inherited risk or another ovarian indication
Cancer preventionLower tubo-ovarian cancer incidence in observational data; does not eliminate serous or other ovarian/peritoneal cancersSubstantial risk reduction in appropriately selected high-risk patients, with residual peritoneal risk
Hormone consequencesRetains ovaries; short-term reserve findings reassuring, long-term endpoints less certainCauses immediate menopause if premenopausal; bone, cardiovascular, sexual and symptom consequences require counseling
Hormone therapyNot required solely because tubes were removedConsider after early surgical menopause, accounting for breast-cancer history and other contraindications
[1][2][5][6][24][29]

Average-risk ovarian conservation at benign hysterectomy should not be generalized to BRCA-associated risk reduction. Likewise, absence of demonstrated long-term harm after salpingectomy is not proof of no cardiovascular, skeletal, or cognitive effect in every patient.

Part X: Salpingectomy with delayed oophorectomy (high-risk patients)​

For BRCA1/2 carriers, RRSO remains the established strategy. Salpingectomy with delayed oophorectomy is under study and must not be presented as equally protective. Gene-specific completion timing and cancer-team counseling remain essential:[8][9]

  • BRCA1 — recommend RRSO between ages 35–40.
  • BRCA2 — reasonable to delay RRSO until ages 40–45.
  • If salpingectomy is performed first, completion oophorectomy is recommended per gene-specific timelines.
  • SEE-FIM protocol and pelvic washings should be performed at salpingectomy.
  • Clinical trials of interval salpingectomy and delayed oophorectomy are ongoing — strong consideration of study participation is recommended.
  • Contraceptive counseling is separate from cancer prevention; a hormonal IUD is not an established substitute for gene-specific risk-reducing surgery.

The prevention benefits of salpingectomy alone are not established as equivalent to RRSO in high-risk patients, and patients remain at risk for developing ovarian cancer after salpingectomy without oophorectomy. NICE specifically restricts the delayed-oophorectomy strategy to clinical trials.[29]

Part XI: Management of incidental adnexal masses​

When an adnexal mass is encountered during surgery, ACOG Practice Bulletin No. 174 provides guidance:[25]

  • Observation depends on high-quality imaging, symptoms, menopause status, size, and cancer risk; a size of 10 cm is not a blanket reassurance threshold. RCOG updated guidance exempts asymptomatic simple unilateral/unilocular postmenopausal cysts ≤3 cm from routine follow-up; cysts >3–5 cm with normal CA125 can undergo repeat assessment, while larger, symptomatic, or complex lesions require further evaluation.[31]
  • Minimally invasive surgery is preferred for presumed benign masses.
  • Ovarian preservation is important in premenopausal patients when oncologically appropriate, including those who have completed childbearing.
  • Aspiration of cyst fluid is generally contraindicated when malignancy is suspected (sensitivity only 50–74%; risk of peritoneal seeding).
  • Adnexal torsion — prompt detorsion and conservation are generally appropriate in young patients when feasible; a dark appearance alone does not establish irreversible loss of function.[25]

The IOTA5 prospective cohort supports surveillance of masses judged benign on ultrasound, rather than incidental-mass reassurance from operative appearance alone. Of 3,144 eligible conservatively managed patients, 2,587 had follow-up data; the newly diagnosed subgroup included 1,919. Its 2-year cumulative incidence was 0.4% invasive malignancy, 0.3% borderline tumor, 0.4% torsion, and 0.2% rupture. This selected population does not establish safety for suspicious or symptomatic masses.[26]

ACOG recommends that counseling for women undergoing routine pelvic surgery include:[1]

  1. The potential benefits of fallopian-tube removal for ovarian-cancer risk reduction.
  2. That OS significantly decreases but does not eliminate ovarian-cancer risk entirely.
  3. An informed-consent discussion about the role of oophorectomy and BSO — including that BSO causes surgical menopause and may increase risks of cardiovascular disease, other cancers, osteoporosis, cognitive impairment, and all-cause mortality.
  4. That ovarian function does not appear to be affected by salpingectomy based on surrogate serum markers.
  5. Discuss surgical approach, likelihood of completing salpingectomy, and incremental risk; the August 2026 ACOG update revises the prior categorical route-counseling advice.[28]
  6. For patients desiring permanent sterilization, the risks and benefits of salpingectomy vs. tubal ligation.

ESGO limits this intervention to patients who no longer want tubal fertility: counsel about permanent sterilization before surgery, with adequate time for consideration, and avoid proceeding through massive adhesions or other disproportionate risk. The ESGO adds that age alone should not be used to withhold OS, although data are insufficient to determine which age group benefits most.[6]

Summary — key principles​

  1. Rationale — most HGSOC originates in the fimbriated end of the fallopian tube (STIC lesions), not the ovarian surface.[3][4]
  2. Risk reduction — observational estimates vary by population and histology; avoid promising a fixed personal reduction.[6]
  3. Safety — perioperative and short-term ovarian-reserve data are generally reassuring; operative time, feasibility, and longer-term uncertainty require counseling.[1][6][15]
  4. Indications — all eligible women undergoing gynecologic surgery; expanding to non-gynecologic abdominopelvic procedures.[6][20][22]
  5. Technique — complete removal from fimbria to uterotubal junction; SEE-FIM pathologic processing recommended.[1][9]
  6. Missed opportunities — ~24% of HGSOC patients had prior surgeries where OS could have been performed; ~60% had ≥1 prior abdominopelvic surgery.[18][19]
  7. Salpingectomy ≠ oophorectomy — OS preserves ovarian function and avoids surgical menopause, fundamentally different from BSO.[1][24]
  8. High-risk patients — delayed oophorectomy is investigational; do not infer RRSO-equivalent cancer protection from quality-of-life benefits.[8][9]
  9. Cost-effectiveness — models project savings in selected settings; results depend on uptake, cancer-risk reduction, complication rates, and local costs.[22][23][27]

See Also​

References​

1. Chohan L, Richardson DL. Opportunistic Salpingectomy as a Strategy for Epithelial Ovarian Cancer Prevention. American College of Obstetricians and Gynecologists; 2019.

2. American College of Obstetricians and Gynecologists. "ACOG Committee Opinion No. 774: opportunistic salpingectomy as a strategy for epithelial ovarian cancer prevention." Obstet Gynecol. 2019;133(4):e279–e284. doi:10.1097/AOG.0000000000003164

3. Pölcher M, Wimberger P, Meinhold-Heerlein I, et al. "Intergroup statement: opportunistic salpingectomy — molecular pathology, clinical outcomes and implications for practice (German Ovarian Cancer Commission, NOGGO, AGO Austria, AGO Swiss)." Arch Gynecol Obstet. 2025;311(5):1451–1459. doi:10.1007/s00404-025-07974-z

4. Sisodia RC, Del Carmen MG. "Lesions of the ovary and fallopian tube." N Engl J Med. 2022;387(8):727–736. doi:10.1056/NEJMra2108956

5. Kahn RM, Gordhandas S, Godwin K, et al. "Salpingectomy for the primary prevention of ovarian cancer: a systematic review." JAMA Surg. 2023;158(11):1204–1211. doi:10.1001/jamasurg.2023.4164

6. Piek JM, Schauwaert J, Ellis LB, et al. "Opportunistic salpingectomy for prevention of tubo-ovarian carcinoma." JAMA. 2026. doi:10.1001/jama.2025.24510

7. Duus AH, Zheng G, Baandrup L, Faber MT, Kjær SK. "Risk of ovarian cancer after salpingectomy and tubal ligation: prospects on histology and time since the procedure." Gynecol Oncol. 2023;177:125–131. doi:10.1016/j.ygyno.2023.08.016

8. National Comprehensive Cancer Network. Genetic / Familial High-Risk Assessment: Breast, Ovarian, Pancreatic, and Prostate. Updated 2026-02-19.

9. National Comprehensive Cancer Network. Ovarian Cancer Including Fallopian Tube Cancer and Primary Peritoneal Cancer. Updated 2026-04-10.

10. Eleje GU, Eke AC, Ezebialu IU, et al. "Risk-reducing bilateral salpingo-oophorectomy in women with BRCA1 or BRCA2 mutations." Cochrane Database Syst Rev. 2018;8:CD012464. doi:10.1002/14651858.CD012464.pub2

11. Samimi G, Trabert B, Duggan MA, et al. "Processing of fallopian tube, ovary, and endometrial surgical pathology specimens: a survey of US laboratory practices." Gynecol Oncol. 2018;148(3):515–520. doi:10.1016/j.ygyno.2018.01.016

12. Maryns AS, Hamerlynck T, van Overberghe C, et al. "Opportunistic salpingectomy: is surgical completeness achieved? Insights from the QOS study." Eur J Obstet Gynecol Reprod Biol. 2026;321:115066. doi:10.1016/j.ejogrb.2026.115066

13. Rufin KGA, do Valle HA, McAlpine JN, Elwood C, Hanley GE. "Complications after opportunistic salpingectomy compared with tubal ligation at cesarean section: a retrospective cohort study." Fertil Steril. 2024;121(3):531–539. doi:10.1016/j.fertnstert.2023.11.031

14. Mandelbaum RS, Matsuzaki S, Sangara RN, et al. "Paradigm shift from tubal ligation to opportunistic salpingectomy at cesarean delivery in the United States." Am J Obstet Gynecol. 2021;225(4):399.e1–399.e32. doi:10.1016/j.ajog.2021.06.074

15. Gelderblom ME, IntHout J, Dagovic L, et al. "The effect of opportunistic salpingectomy for primary prevention of ovarian cancer on ovarian reserve: a systematic review and meta-analysis." Maturitas. 2022;166:21–34. doi:10.1016/j.maturitas.2022.08.002

16. Hanley GE, Kwon JS, McAlpine JN, et al. "Examining indicators of early menopause following opportunistic salpingectomy: a cohort study from British Columbia, Canada." Am J Obstet Gynecol. 2020;223(2):221.e1–221.e11. doi:10.1016/j.ajog.2020.02.005

17. Mandelbaum RS, Adams CL, Yoshihara K, et al. "The rapid adoption of opportunistic salpingectomy at the time of hysterectomy for benign gynecologic disease in the United States." Am J Obstet Gynecol. 2020;223(5):721.e1–721.e18. doi:10.1016/j.ajog.2020.04.028

18. Moufarrij S, Hazimeh D, Rockwell T, et al. "Gauging the magnitude of missed opportunity for ovarian cancer prevention." JAMA Surg. 2025. doi:10.1001/jamasurg.2025.2810

19. Tischer KM, Islam NS, McGree ME, et al. "Quantifying opportunities to reduce high-grade serous ovarian cancer via opportunistic salpingectomy." Gynecol Oncol. 2025;203:165–170. doi:10.1016/j.ygyno.2025.10.028

20. Matsuo K, Chen L, Matsuzaki S, et al. "Opportunistic salpingectomy at the time of laparoscopic cholecystectomy for ovarian cancer prevention: a cost-effectiveness analysis." Ann Surg. 2023;277(5):e1116–e1123. doi:10.1097/SLA.0000000000005374

21. Wright JD, Chen L, Tymm C, et al. "Population-level reduction in ovarian cancer through performance of opportunistic salpingectomy at the time of cholecystectomy." Ann Surg. 2025. doi:10.1097/SLA.0000000000006940

22. Adjei NN, Yeh PG, Haas A, et al. "Opportunistic salpingectomy during gynecologic and non-gynecologic abdominopelvic procedures for ovarian cancer primary prevention: a cost-effectiveness analysis." Int J Gynecol Cancer. 2025:102884. doi:10.1016/j.ijgc.2025.102884

23. Kather A, Arefian H, Schneider C, Hartmann M, Runnebaum IB. "Ovarian cancer prevention through opportunistic salpingectomy during abdominal surgeries: a cost-effectiveness modeling study." PLoS Med. 2025;22(1):e1004514. doi:10.1371/journal.pmed.1004514

24. Adelman MR, Sharp HT. "Ovarian conservation vs removal at the time of benign hysterectomy." Am J Obstet Gynecol. 2018;218(3):269–279. doi:10.1016/j.ajog.2017.07.037

25. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Gynecology. "Practice Bulletin No. 174: evaluation and management of adnexal masses." Obstet Gynecol. 2016;128(5):e210–e226. doi:10.1097/AOG.0000000000001768

26. Froyman W, Landolfo C, De Cock B, et al. "Risk of complications in patients with conservatively managed ovarian tumours (IOTA5): a 2-year interim analysis of a multicentre, prospective, cohort study." Lancet Oncol. 2019;20(3):448–458. doi:10.1016/S1470-2045(18)30837-4

27. Naumann RW, Hughes BN, Brown J, Drury LK, Herzog TJ. "The impact of opportunistic salpingectomy on ovarian cancer mortality and healthcare costs: a call for universal insurance coverage." Am J Obstet Gynecol. 2021;225(4):397.e1–397.e6. doi:10.1016/j.ajog.2021.03.032

28. American College of Obstetricians & Gynecologists Committee on Clinical Consensus–Gynecology. "Salpingectomy for the Prevention of Epithelial Ovarian Cancer." August 2026. doi:10.1097/AOG.0000000000006400. ACOG-authored announcement, August 20.

29. NICE. Ovarian cancer: identifying and managing familial and genetic risk. NG241, 2024. Recommendations.

30. Sowamber R, Mei AJ, Kaur P, et al. "Serous Ovarian Cancer Following Opportunistic Bilateral Salpingectomy." JAMA Netw Open. 2026;9:e2557267. doi:10.1001/jamanetworkopen.2025.57267.

31. RCOG. The Management of Ovarian Cysts in Postmenopausal Women. Green-top Guideline34, amended December 2025. Guideline.

32. Subramaniam A, et al. "Feasibility of Complete Salpingectomy Compared With Standard Postpartum Tubal Ligation at Cesarean Delivery: A Randomized Controlled Trial." Obstet Gynecol. 2018. Primary trial.