Tubal anastomosis after tubal sterilization: a review

A novel machine learning model for predicting clinical pregnancy after laparoscopic tubal anastomosis

BACKGROUND

Laparoscopic tubal anastomosis (LTA) is a treatment for women who require reproduction after ligation, and there are no reliable prediction models or clinically useful tools for predicting clinical pregnancy in women who receive this procedure. The prediction model we developed aims to predict the individual probability of clinical pregnancy in women after receiving LTA.

METHODS

Retrospective analysis of clinical data of patients undergoing LAT in the Second Hospital of Lanzhou University from July 2017 to December 2021. Least absolute shrinkage and selection operator (LASSO) regression was used for data dimension reduction and feature selection. We incorporated the patients' basic characteristics, preoperative laboratory tests and laparoscopic tubal anastomosis procedure signature and obtained a nomogram. The model performance was evaluated in terms of its calibration, discrimination, and clinical applicability. The prediction model was further internally validated using 200 bootstrap resamplings.

RESULTS

A total of 95 patients were selected to build the predictive model for clinical pregnancy after LTA. The LASSO method identified age, intrauterine polyps, pelvic adhesion and thyroid stimulating hormone(TSH) as independent predictors of the clinical pregnancy rate. The prediction nomogram included the abovementioned four predictive parameters. The model showed good discrimination with an area under the curve (AUC) value of 0.752. The Hosmer‒Lemeshow test of calibration showed that χ2 was 4.955 and the p value was 0.838, which indicates a satisfactory goodness-of-fit. Decision curve analysis demonstrated that the nomogram was clinically useful. Internal validation shows that the predictive model performs well.

CONCLUSION

This study presents a nomogram incorporating age, intrauterine polyps, pelvic adhesion and TSH based on the LASSO regression model, which can be conveniently used to facilitate the individualized prediction of clinical pregnancy in women after LTA.

A brief history and future prospects of contraception

Modern contraception ushered in an era of improved family planning, but more than 60 years after approval of "the pill," product gaps and unmet needs still exist. Nearly 250 million women worldwide who want to delay or avoid pregnancy do so ineffectively or not at all, and the principal mechanism of male contraception, condoms, has not changed in 100 years. As a result, about half of the pregnancies that occur globally each year are unintended. Increasing contraceptive options and uptake will curtail abortions, empower women and men, promote healthy families, and moderate population growth that overtaxes the environment. This Review addresses the history of contraception, shortcomings in contraceptive methods, promising approaches for male and female contraception, and simultaneous protection against unintended pregnancy and sexually transmitted infections.

Laparoscopic Reversal of Tubal Sterilization; A Retrospective Study Over 135 Cases

Objectives: To evaluate the pregnancy and delivery rates of laparoscopic tubal reanastomosis.

Study Design: From 2003 to 2013, 135 laparoscopic tubal reversals were performed according to the four stitch technique. The parameters studied, included positive pregnancy test, miscarriage, ectopic pregnancy, termination of pregnancy, term delivery, post-operative time to conception, post-operative hysterosalpingography, and spermogram.

Results: From the 135 patients operated, 93 fulfilled the inclusion criteria. The age of patients varied from 27 to 47 years old. All ages combined, positive β-HCG blood sample rate was 75.3% (95% CI: 65.0–83.4%) and term delivery 52.7% (95%CI: 42.1–3.0%). The age-adjusted pregnancy and delivery rates were as follows:

27–35 y.o. (n = 23) 95.7% (95%CI: 76.0–99.8%) and 73.9% (95%CI: 51.3–88.9%),

36–39 y.o. (n = 40) 77.5% (95%CI: 61.1–88.6%) and 47.5% (95%CI: 31.8–63.7%),

40–42 y.o. (n = 19) 68.4% (95%CI: 43.5–86.4%) and 52.6% (95%CI: 29.5–74.8%),

43–47 y.o. (n = 11) 36.4% (95%CI: 12.4–68.4%) and 27.3% (95%CI: 7.3–60.7%).

Conclusions: In our series the pregnancy and delivery rates after laparoscopic reversal of tubal sterilization is estimated at 75.3 and 52.7%, respectively. For women with tubal sterilization and no other infertility factors, reanastomosis can restore anterior natural fertility related to age. Laparoscopic reversal should be proposed systematically to patients and performed by well-trained laparoscopists, avoiding potentially the inconvenient and adverse outcomes of an IVF treatment. Although, it may seem a more cost-effective technique compared to robotically assisted reversal, a prospective randomized trial could answer this question.

The comparison of the degree of apoptosis in ovaries and fallopian tubes between two different surgical interventions for tubal ligation: A rat model

Objective:

To compare the degree of apoptosis in ovaries and tubal epithelium observed secondary to tubal ligation either by Pomeroy’s method or bipolar electrocauterization in a rat model.

Material and Methods:

A total of 24 female Sprague-Dawley rats were randomly assigned into 3 study groups: control (n=8), Pomeroy (n=8), and the electrocauterization group (n=8). Apoptotic cells were detected on the primary, secondary, tertiary follicles of the ovaries, and on the tubal epithelium using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling. The apoptotic index was calculated for each group by the percentage of the stained cells.

Results:

The apoptotic index of tubal epithelium was significantly higher in the bipolar electrocauterization group compared with the control and Pomeroy groups (3.1±0.8 vs. 1.4±1.0, p=0.018 and 2.0±1.2, p=0.03, respectively) whereas there was no significant difference between Pomeroy’s method and the control group. The apoptotic index of primary follicles was higher in the bipolar electrocauterization group compared with the control and Pomeroy’s method groups (3.4±0.5 vs. 1.2±0.4, p<0.001 and 1.8±0.8, p=0.005, respectively), but there was no significant difference between Pomeroy’s method and the control group. The apoptotic index of secondary and tertiary follicles was similar for each group.

Conclusion:

Pomeroy’s technique, as a permanent contraception method, is associated with lower apoptotic index on ovary and fallopian tube when compared with bipolar electrocauterization.

Robotic-assisted laparoscopy in reproductive surgery: a contemporary review

Robotic surgery is a conceptual fusion of the conventional open surgery and the minimally invasive laparoscopic surgery. We reviewed the current role of robotic-assisted laparoscopy in the field of reproductive surgery by a literature search in PubMed database. We analyzed the reported advantages and limitations of the use of robotics in reproductive surgeries like myomectomy, tubal reanastomosis, endometriosis, ovarian tissue cryopreservation, and ovarian transposition. Overall, robotic assistance in reproductive surgery resulted in decreased blood loss, less post-operative pain, shorter hospital stay, and faster convalescence, whereas reproductive outcomes were similar to open/laparoscopic approaches. The main drawbacks of robotic surgery were higher cost and longer operating times. It is as safe and effective as the conventional laparoscopy and represents a reasonable alternate to abdominal approach. Procedures that are technically challenging with the conventional laparoscopy can be performed with robotic assistance. It has advantages of improved visualization and Endowrist™ movements allowing precise suturing. This helps to overcome the limitations of laparoscopy, especially in complicated procedures, and may shorten the steep learning curve in minimal invasive surgery. Randomized controlled trials looking at both short- and long-term outcomes are warranted to strengthen the role of robotic surgery in the field of reproductive surgery.

Effectiveness of bilateral tubotubal anastomosis in a large outpatient population

STUDY QUESTION

Is bilateral tubotubal anastomosis a successful treatment in an outpatient patient population?

SUMMARY ANSWER

For women wanting children after tubal sterilization, bilateral tubotubal anastomosis is an effective outpatient treatment.

WHAT IS KNOWN ALREADY

With the current emphasis in reproductive medicine on high technology procedures, the effectiveness of female surgical sterilization reversal is often overlooked. Previous clinical studies of tubal sterilization reversal have been mostly retrospective analyses of small patient populations.

STUDY DESIGN, SIZE, DURATION

A cohort of women who underwent outpatient bilateral tubotubal anastomosis from January 2000 to June 2013 was followed prospectively until December 2014 to determine the proportions of women undergoing the procedure who became pregnant and who had live births. Data were collected at the time of pregnancy. Differences in pregnancy rates and live birth rates associated with age, race and sterilization method were evaluated.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A total of 6692 women, aged 20-51 years, underwent outpatient bilateral tubotubal anastomosis.

MAIN RESULTS AND THE ROLE OF CHANCE

The crude overall pregnancy rate was 69%. The crude overall birth rate was 35%. Results varied according to age at sterilization reversal and the method of sterilization. Women under 30 years of age at reversal of ring/clip sterilizations had an 88% pregnancy rate and 62% birth rate. Pregnancy and birth rates declined as age increased at sterilization reversal. Coagulation sterilization reversals resulted in the lowest rates of pregnancies and births. Ligation/resection reversals had intermediate success rates.

LIMITATIONS, REASONS FOR CAUTION

Limitations of our study include probable underreporting of pregnancies based on patient-initiated reports; possible errors in the reporting of pregnancies or early miscarriages that may have been based solely on home pregnancy tests; and probable over-reporting of the diagnosis of ectopic pregnancies. We identified age and sterilization method as being associated with subsequent pregnancy, however, in order to be considered predictive, the associations would need to be validated in an independent second prospectively studied group of representative patients. Finally, we also included patients in the study population who had additional surgical procedures performed at the time of tubotubal anastomosis (e.g. uterine myomectomy, fimbrioplasty, ovarian cystectomy and adhesiolysis), factors that could result in differences in pregnancy statistics in our study versus other patient populations.

WIDER IMPLICATIONS OF THE FINDINGS

The results of this study can help inform patients and clinicians about this low technology alternative to IVF.

STUDY FUNDING/COMPETING INTERESTS

None.

TRIAL REGISTRATION NUMBER

N/A.

Permanent contraception for women

Permanent methods of contraception are used by an estimated 220 million couples worldwide, and are often selected due to convenience, ease of use and lack of side effects. A variety of tubal occlusion techniques are available for female permanent contraception, and procedures can be performed using a transcervical or transabdominal approach. This article reviews currently available techniques for female permanent contraception and discusses considerations when helping patients choose a contraceptive method and tubal occlusion technique.

Fertility outcome analysis after surgical management of tubal ectopic pregnancy: a retrospective cohort study

OBJECTIVES

To compare the subsequent fertility and risk of recurrence of an ectopic pregnancy (EP) in women who had had an EP, according to the type of surgical treatment they received--that is, salpingectomy, salpingostomy or tubal anastomosis.

METHODS

A retrospective cohort study was carried out between January 2003 and September 2011 of 618 patients admitted to hospital with tubal EP and who had received surgical treatment (salpingectomy, n=434; salpingostomy, n=112; and tube anastomosis, n=72). Main outcomes included the first intrauterine pregnancy (IUP) and recurrent EP.

RESULTS

The crude IUP rates up to 24 months after surgery were 55.5% for salpingectomy, 50.9% for salpingostomy and 40.3% for tubal anastomosis treatments. In the multivariate-adjusted model, with the patients receiving salpingectomy as the reference group, HR for patients after salpingostomy and tubal anastomosis treatments for IUP were 0.912 (95% CI 0.762 to 2.017) and 0.619 (95% CI 0.328 to 0.927), respectively. The 2-year cumulative recurrent EP rates were found to be 8.1% for salpingectomy, 6.3% for salpingostomy and 16.7% for tubal anastomosis treatments. Taking the patients receiving salpingectomy as the reference group, the patients who received tubal anastomosis had a positively higher risk of recurrent EP (HR=2.280; 95% CI 1.121 to 4.636) in univariate analysis. Adjustment for other potential confounders only slightly attenuated the HR.

CONCLUSIONS

The patients with an EP receiving tubal anastomosis treatments appeared to have a lower 2-year rate of IUP and a higher risk of recurrent EP after adjustment for other potential risk factors.

Laparoscopic tubal reanastomosis versus in vitro fertilization: cost-based decision analysis

OBJECTIVE

Regret after tubal ligation continues to be a problem. After tubal ligation, couples have the option of tubal surgery or in vitro fertilization (IVF).

STUDY DESIGN

Using decision analysis techniques, we compared cost-effectiveness of tubal reanastomosis by tubal type vs tubal surgery or in vitro fertilization (IVF) for 3 separate age groups of women: <35 years of age, 35 to 40 years of age and >40 years of age. Tubal techniques was divided into type A, those with more favorable prognosis because of the likelihood of having a more significant length tube at time of reanastomosis and type B, those with a worse prognosis of success. We incorporated delivery costs to address the impact of high order multiples in IVF. Data were extracted by studies available in the literature. All costs were adjusted to 2012 US dollars. One-way and 2-way sensitivity analyses were performed.

RESULTS

The laparoscopic reanastomosis of type A dominated the other groups, because it was more effective and less costly then type B and IVF. However, when women were >40 years old with a history of type B, IVF was favored when its costs were at the lower limit.

CONCLUSION

The most cost-effective choice for a woman desiring pregnancy after tubal ligation is laparoscopic reanastomosis after a prior clip or ring tubal ligation for women ≤40 years old. It is also the most cost-effective for the oldest cohort, assuming IVF costs are greater than $4500.

[Robot-assisted coelioscopic proximal tubal reanastomosis]

We report two cases of robot-assisted coelioscopic proximal tubal reanastomosis after proximal tubal ligature. Patients were aged 43 and 34 years respectively and had previously undergone proximal tubal ligation by coagulation section at 37 years of age for the first patient, and by Filshie clip at 24 years for the second one. Both had regular menstrual cycles and their ovarian reserve was good. Their partners were presenting with normal sperm criteria. Proximal tubal reanastomosis was carried out in September 2010 by robotic coelioscopy with five extramucous vicryl 5-0 stitches on each tube and positive blue testing. Total durations of the interventions were 200 and 220minutes respectively. Postoperative outcomes were simple and patients had spontaneous pregnancy at 4 and 2.5 months respectively. Both pregnancies show normal progress currently. This is a contribution to literature data meant to determine the role of robotics in proximal tubal reanastomosis.