Microsurgical reversal of tubal sterilization: a report on 1,118 cases

Where Microsurgical Tubal Reanastomosis Stands in the In vitro Fertilization Era

Among various options of contraception, bilateral tubal ligation (BTL) remains the most frequently used method for women worldwide even at present. However, up to 30% of those who undergo BTL eventually change their minds and wish to conceive again for a variety of reasons, such as a change in marital status or simply wanting more children. In this case, we can either approach it surgically with tubal re-anastomosis (TA) or by in vitro fertilization (IVF)-embryo transfer. Despite the many advantages of TA which lead the American Society of Reproductive Medicine Committee Opinion to recommend it as the primary choice of treatment in posttubal ligation infertility in 2012, IVF is widely being chosen as the first-line treatment nowadays. This study will review the efficacy of TA in various aspects, including pregnancy rate, cost-effectiveness, feasibility, and accessibility, based on review of the literature and our experience. Through this study, we intend to provide a basis for gynecologists to consider TA as the first option in women who wish to conceive again after BTL in this day and age of IVF.

Female sterilization reversal in the era of in-vitro fertilization

PURPOSE OF REVIEW

Regret after female sterilization is not uncommon in the United States. Prior to the development of assisted reproductive technology (ART), surgical reversal of sterilization was the only option for patients interested in fertility. First performed in 1972, this procedure has since been refined over the years by gynaecologic surgeons. With in-vitro fertilization (IVF) gaining popularity, interest in sterilization reversal has waned. However, sterilization reversal should remain an important option in patients seeking pregnancy after tubal ligation.

RECENT FINDINGS

A direct comparison between IVF and sterilization reversal is challenging due to inherent differences in reporting fertility outcomes. However, sterilization reversal may optimize fertility in younger women, whereas IVF may be more effective in older women. The surgical approach to sterilization reversal can be laparotomic, laparoscopic or robotic. Clinical decision making should include consideration of the risk of ectopic pregnancy, interval from sterilization to reversal, type of sterilization procedure, planned anastomotic site and projected remaining tubal length.

SUMMARY

In the era of IVF, sterilization reversal still has a place in the management in restoring fertility. Creating awareness of the role of sterilization reversal is the first step in improving access to adequate training in this procedure for the next generation of reproductive surgeons.

Robot-Assisted Tubal Reanastomosis after Sterilization: A Choice for Family Planning

A variety of procedures have been used for family planning. One of these is sterilization surgery, which can be reversed by a tubal reanastomosis. In the present report, we compare Robot-assisted tubal reanastomosis sterilization with other methods of family planning and discuss factors related to the choice of the approach. The keywords used for the electronic search in PubMed were family planning, sterilization, Robot-assisted, tubal reanastomosis, depression, and regret. The decision in favor of or against sterilization surgery has been a sensitive issue for several years. Robot-assisted technology is a modern and precise approach. It has contributed to the flexibility of the decision between sterilization and its reversal through tubal reanastomosis, as well as enhanced the success rate of the surgery. Based on our analysis of the published literature, we believe that Robot-assisted tubal anastomosis is the optimum approach. However, to ensure the quality of health care, the surgeon must be well trained, well versed with the anatomy of the fallopian tubes, and thoroughly informed on the psychological impact of family planning.

Is there any difference between pregnancy results after tubal reanastamosis performed laparotomically, laparoscopically, and robotically?

INTRODUCTION

Tubal reanastamosis offers hope to conceive again. However, there are many factors that affect the success of this procedure. In our study we aimed to compare the pregnancy rates of the surgical methods used for tubal reanastamosis in pregnancy requested after tubal sterilization.

METHODS

In our study we compared the rates of pregnancies after reanastamosis retrospectively in female patients under the age of 40 who underwent reanastamosis between 2010 and 2019 with laparotomic, laparoscopic and robotic methods. A single layer of 4 quadrant 6/0 number polydioxanone absorbable sutures were used in all surgical methods. A similar surgical technique was used.

RESULTS

In surgical methods (laparotomy, laparoscopy, and robotics), there was a statistical difference between the three groups in terms of operation times of surgical methods used for tubal reanastamosis (p < 0.05). Laparotomy, laparoscopy, and robotics pregnancy rates were 52.6% (n = 41), 67.3% (n = 37), 61.2% (n = 63), respectively. There was no statistical difference between groups in terms of pregnancy rates. However, odds ratio (OR) values of the laparoscopy group and robotics group probability of conception were 1.536 (95% confidence interval [CI], 0.813-2.898), 1.111 (95% CI, 0.656-1.879) higher, respectively.

CONCLUSIONS

Although there is no statistical difference between the surgical methods used for tubal reanastamosis, we think that the laparoscopic surgical method may be preferable due to the shorter hospital stay. We think that the previous method of bilateral tubaligastion (BTL), the site of reanastasis, and the time between BTL and reanastomosis were effective in pregnancy success.

Sterilization regret in India: Is quality of care a matter of concern?

Background

According to United Nations, 19% of females in the world relied only on the permanent method of family planning, with 37% in India according to NFHS-4. Limited studies tried to measure the sterilization regret, and its correlated factors. The study tried to explore the trend of sterilization regret in India from 1992 to 2015 and to elicit the determining effects of various factors on sterilization regret, especially in context to perceived quality of care in the sterilization operations and type of providers.

Data and methods

The pooled data from NFHS-1, NFHS-3 and NFHS-4 was used to explore the regret by creating interaction between time and all the predictors. Predicted probabilities were calculated to show the trend of sterilization regret amounting to quality of care, type of health provider at the three time periods.

Results

The sterilization regret was increased from 5 % in NFHS-1 to 7 % in NFHS-4. According to NFHS-4, for those whose sterilization was performed in private health facility the regret was found to be less (OR-0.937; 95% CI- (0.882–0.996)) compared to public health facility. Also, the results show a two-fold increase in regret when women reported bad quality of care. The results from predicted probabilities provide enough evidence that the regret due to bad quality of care in sterilization operation had increased with each subsequent round of NFHS.

Conclusion

Many socio-economic and demographic factors have influenced the regret, but the poor quality of care contributed maximum to the regret from 1992 to 2015. The health facilities have seriously strayed from improving the health and well-being of women in providing the family planning methods. In addition, to public facilities, the regret amounting to private facilities have also increased from NFHS-1 to 4. The quality of care provided in the family planning operation should be standardized in every hospital to strengthen the health systems in the country. The couple should be motivated to adopt more of spacing methods.

Role of Reconstructive Microsurgery in Tubal Infertility in Young Women

AIM

Here, we retrospectively analyzed the success rate of reconstructive microsurgery for tubal infertility (RMTI) as a "first-line" approach to achieving tubal reversal and pregnancy after tubal infertility.

PATIENTS AND METHODS

During 9 consecutive years (2005-2014), 96 patients diagnosed with obstructive tubal infertility underwent RMTI (tubal reversal, salpingostomy, and/or tubal implantation) in our centre. The outcomes are presented in terms of tubal reversal rate and pregnancy and correlated with age, level of tubal obstruction, and duration of tubal infertility.

RESULTS

The overall tubal reversal rate was 87.56% (84 patients). The 48-month cumulative pregnancy rate was 78.04% (64 patients), of which seven ectopic pregnancies occurred (8.53%). The reversibility rate for women under 35 yo was 90.47%, with a birth rate of 73.01%. The reconstruction at the infundibular segments favored higher ectopic pregnancy rates (four ectopic pregnancies for anastomosis at infundibular level-57.14%, two for ampullary level-28.57%, and one for replantation technique-14.28%), with a significant value for p < 0.05.

CONCLUSIONS

In the context of IVF "industrialization", reconstructive microsurgery for tubal infertility has become increasingly less favored. However, under available expertise and proper indication, RMTI can be successfully used to restore a woman's ability to conceive naturally with a high postoperative pregnancy rate overall, especially in women under 35 yo.

Laparoscopic Tubal Re-anastomosis or In Vitro Fertilisation in Previously Ligated Patients: A Comparison of Fertility Outcomes and Survey of Patient Attitudes

Introduction: We aim to compare live birth rates, cost analysis and a survey of patient attitudes between laparosopic tubal re-anastomosis and IVF. Materials and Methods: Retrospective study: A retrospective study was done in a single reproductive medicine and IVF unit in Singapore, from January 2011 to December 2016. Previously ligated patients underwent either laparoscopic tubal re-anastomosis or IVF. The primary outcome was first live birth after treatment. Interval to first pregnancy, miscarriage and ectopic pregnancies were also reported. Survey: Patients attending the subfertility clinic completed a questionnaire on IVF and tubal re-anastomosis, on preferred choice of treatment, before and after reading an information sheet. Results: Retrospective study: 12 patients underwent tubal re-anastomosis while 31 patients underwent IVF treatment. Pregnancy (75.0% vs 35.5%) and live birth (58.3% vs 25.8%) were significantly higher in the tubal surgery group (P<0.05%) after transferring all available embryos in one stimulated IVF cycle. Cost per live birth was lower in the tubal surgery group (SGD27,109 vs SGD52,438). Survey: One hundred patients participated in the survey. A majority of patients preferred tubal surgery to IVF (68.2% vs 31.8%) before given information on the procedures, but indicated a preference for IVF (54.6%) to surgery (45.4%) after receiving information on the procedures. Conclusion: For women less than 40 years of age, desiring fertility after tubal ligation, laparoscopic tubal re-anastomosis offers better live birth rates and cost-effectiveness. Patients in Singapore are equivocal as to their preference after education regarding the choices. Thus laparoscopic tubal re-anastomosis remains a viable alternative to IVF treatment. Key words: Artificial reproductive technology, Laparoscopic tubal reversal, Previous tubal ligation

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.

Pregnancy outcome of laparoscopic tubal reanastomosis: retrospective results from a single clinical centre

Objective Tubal sterilization is a widespread method of contraception. Post-sterilization regret is encountered, despite careful consideration prior to the procedure. Two treatment options are available for women after having had tubal sterilization: microsurgical reversal and IVF treatment. Recent improvements in laparoscopy have allowed tubal reanastomosis to be performed. This study aimed to evaluate the reproductive outcome after laparoscopic tubal reanastomosis and surgical features of the patients. Methods From June 2007 to January 2010, 27 patients with bilateral tubal ligation who underwent laparoscopic tubal reanastomosis were evaluated retrospectively. Tubal sterilization was performed by Pomeroy's technique during caesarean section in all of the patients. Before surgery, all of the patients were evaluated for possible other causes of infertility and the results of the evaluation were normal. Results The mean age of the patients was 31.8 years (range, 27-38 years). The mean interval between sterilization and reversal was 5.1 years (range, 1-14 years). Bilateral reversal was achieved in 24 patients. The operation time ranged from 85 to 140 minutes with a mean time of 105 minutes. All of the patients were discharged on the next day. There were no postoperative complications. Overall pregnancy, intrauterine pregnancy, and ectopic pregnancy rates were 55.5% (15/27), 51.8% (14/27), and 3.7% (1/27), respectively. Of the 14 intrauterine pregnancies, one ended with abortion at 6 weeks' gestation (1/14). The mean interval from surgery to pregnancy was 270 days (range, 147-420 days). Conclusion Laparoscopic tubal reanastomosis has the advantages of fewer complications, less postoperative discomfort, a smaller incisional scar, a shorter recovery time, and earlier resumption of normal activities. This technique has a satisfactory pregnancy rate in selected patients who desire reversal of tubal sterilization.

Tubal anastomosis after previous sterilization: a systematic review

BACKGROUND

Female sterilization is one of the most common contraceptive methods. A small number of women, however, opt for reversal of sterilization procedures after they experience regret. Procedures can be performed by laparotomy or laparoscopy, with or without robotic assistance. Another commonly utilized alternative is IVF. The choice between surgery and IVF is often influenced by reimbursement politics for that particular geographic location.

OBJECTIVE AND RATIONALE

We evaluated the fertility outcomes of different surgical methods available for the reversal of female sterilization, compared these to IVF and assessed the prognostic factors for success.

SEARCH METHODS

Two search strategies were employed. Firstly, we searched for randomized and non-randomized clinical studies presenting fertility outcomes of sterilization reversal up to July 2016. Data on the following outcomes were collected: pregnancy rate, ectopic pregnancy rate, cost of the procedure and operative time. Eligible study designs included prospective or retrospective studies, randomized controlled trials, cohort studies, case-control studies and case series. No age restriction was applied. Exclusion criteria were patients suffering from tubal infertility from any other reason (e.g. infection, endometriosis and adhesions from previous surgery) and studies including <10 participants. The following factors likely to influence the success of sterilization reversal procedures were then evaluated: female age, BMI and duration and method of sterilization. Secondly, we searched for randomized and non-randomized clinical studies that compared reversal of sterilization to IVF and evaluated them for pregnancy outcomes and cost effectiveness.

OUTCOMES

We included 37 studies that investigated a total of 10 689 women. No randomized controlled trials were found. Most studies were retrospective cohort studies of a moderate quality. The pooled pregnancy rate after sterilization reversal was 42-69%, with heterogeneity seen from the different methods utilized. The reported ectopic pregnancy rate was 4-8%. The only prognostic factor affecting the chance of conception was female age. The surgical approach (i.e. laparotomy [microscopic], laparoscopy or robotic) had no impact on the outcome, with the exception of the macroscopic laparotomic technique, which had inferior results and is not currently utilized. For older women, IVF could be a more cost-effective alternative for the reversal of sterilization. However, direct comparative data are lacking and a cut-off age cannot be stated.

WIDER IMPLICATIONS

In sterilized women who suffer regret, surgical tubal re-anastomosis is an effective treatment, especially in younger women. However, there is a need for randomized controlled trials comparing the success rates and costs of surgical reversal with IVF.

Robot-assisted segmental resection of tubal pregnancy followed by end-to-end reanastomosis for preserving tubal patency and fertility: An initial report

The objective of this study was to evaluate whether robotic tubal reanastomosis after segmental resection of tubal pregnancy is a feasible means of preserving tubal integrity and natural fertility in those with compromised contralateral tubal condition.The study was performed at a university medical center in a retrospective manner where da Vinci robotic system-guided segmental resection of tubal ectopic mass followed by reanastomosis was performed to salvage tubal patency and fertility in those with a single viable fallopian tube. Of the 17 patients with tubal pregnancies that were selected, 14 patients with successful tubal segmental resection and reanastomosis were followed up. The reproducibility of anastomosis success and cumulative pregnancy rates of up to 24 months were analyzed.Patient mean age was 28.88 ± 4.74 years, mean amenorrheic period was 7.01 ± 1.57 weeks and mean human chorionic gonadotropin (hCG) level was 9289.00 ± 7510.00 mIU/mL. The overall intraoperative cancellation rate due to unfavorable positioning or size of the tubal mass was 17.65% (3/17), which was converted to either salpingectomy or milking of ectopic mass. Of the 14 attempted, anastomosis for all 14 cases was successful, with 1 anastomotic leakage. One patient wishing to postpone pregnancy and 2 patients where patency of the contralateral tube was confirmed during the operation, were excluded from the pregnancy outcome analysis. Cumulative pregnancy rate was 63.64% (7/11), with 3 (27.27%) ongoing pregnancies, 3 (27.27%) livebirths, and 1 missed abortion at 24 months. During the follow-up, hysterosalpingography (HSG) was performed at 6 months for those who consented, and all 10 fallopian tubes tested were patent. No subsequent tubal pregnancies occurred in the reananstomosed tube for up to a period 24 months.For patients with absent or defective contralateral tubal function, da Vinci-guided reanastomosis after segmental resection of tubal pregnancy is feasible for salvaging tubal patency and fertility.

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.

Live delivery outcome after tubal sterilization reversal: a population-based study

OBJECTIVE

To determine the cumulative incidence of live delivery in women who underwent reversal of tubal sterilization.

DESIGN

Population-based retrospective cohort study.

SETTING

Hospitals in Western Australia.

PATIENT(S)

All women aged 20-44 years, with a history of hospital admission for tubal sterilization, who subsequently underwent reversal of sterilization during the period 1985 to 2009 in Western Australia (n = 1,898).

INTERVENTION(S)

Data regarding reversal of sterilization and prior tubal sterilization were extracted from routinely collected administrative hospital separation records, until commencement of IVF treatment.

MAIN OUTCOME MEASURE(S)

First live-delivery rates.

RESULT(S)

There were 969 first live deliveries observed during the study period. The overall cumulative live-delivery rate was 20% (95% confidence interval [CI] 18-23) within the first year after reversal, 40% (95% CI 38-42) at 2 years, 51% (95% CI 48-53) at 5 years, and 52% (95% CI 50-55) at 10 years. The 5-year cumulative live-delivery rate was significantly lower in women who were aged 40-44 years (26%) compared with younger women (aged 20-29, 30-34, and 35-39 years) (50%, 56%, and 51%, respectively).

CONCLUSION(S)

Women undergoing reversal of sterilization before they reach age 40 years have at least a 50% chance of delivering a live baby within the next 5 years. Up to that age, there is no significant difference in live deliveries. The live-delivery rate halves after the age of 40 years.

Cost and efficacy comparison of in vitro fertilization and tubal anastomosis for women after tubal ligation

OBJECTIVE

To compare cost and efficacy of tubal anastomosis to in vitro fertilization (IVF) in women who desired fertility after a tubal ligation.

DESIGN

Cost-effectiveness analysis.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Cost per ongoing pregnancy.

RESULT(S)

Cost per ongoing pregnancy for women after tubal anastomosis ranged from $16,446 to $223,482 (2014 USD), whereas IVF ranged from $32,902 to $111,679 (2014 USD). Across maternal age groups <35 and 35-40, years tubal anastomosis was more cost effective than IVF for ongoing pregnancy. Sensitivity analyses validated these findings across a wide range of ongoing pregnancy probabilities as well as costs per procedure.

CONCLUSION(S)

Tubal anastomosis was the most cost-effective approach for most women less than 41 years of age, whereas IVF was the most cost-effective approach for women aged ≥41 years who desired fertility after tubal ligation. A model was created that can be modified based on cost and success rates in individual clinics for improved patient counseling.

Contraceptive Use and the Risk of Ectopic Pregnancy: A Multi-Center Case-Control Study

Objective

To evaluate the association between the risk of ectopic pregnancy (EP) and the use of common contraceptives during the previous and current conception/menstrual cycle.

Methods

A multi-center case-control study was conducted in Shanghai. Women diagnosed with EP were recruited as the case group (n = 2,411). Women with intrauterine pregnancy (IUP) (n = 2,416) and non-pregnant women (n = 2,419) were matched as controls at a ratio of 1∶1. Information regarding the previous and current use of contraceptives was collected. Multivariate logistic regression analyses were performed to calculate odds ratios (ORs) and the corresponding 95% confidential intervals (CIs).

Results

Previous use of intrauterine devices (IUDs) was associated with a slight risk of ectopic pregnancy (AOR₁ = 1.87 [95% CI: 1.48–2.37]; AOR₂ = 1.84 [1.49–2.27]), and the risk increased with the duration of previous use (P₁ for trend <10⁻⁴, P₂ for trend <10⁻⁴). The current use of most contraceptives reduced the risk of both unwanted IUP (condom: AOR = 0.04 [0.03–0.05]; withdrawal method: AOR = 0.10 [0.07–0.13]; calendar rhythm method: AOR = 0.54 [0.40–0.73]; oral contraceptive pills [OCPs]: AOR = 0.03 [0.02–0.08]; levonorgestrel emergency contraception [LNG-EC]: AOR = 0.22 [0.16–0.30]; IUDs: AOR = 0.01 [0.005–0.012]; tubal sterilization: AOR = 0.01 [0.001–0.022]) and unwanted EP (condom: AOR₁ = 0.05 [0.04–0.06]; withdrawal method: AOR₁ = 0.13 [0.09–0.19]; calendar rhythm method: AOR₁ = 0.66 [0.48–0.91]; OCPs: AOR₁ = 0.14 [0.07–0.26]; IUDs: AOR₁ = 0.17 [0.13–0.22]; tubal sterilization: AOR₁ = 0.04 [0.02–0.08]). However, when contraception failed and pregnancy occurred, current use of OCPs (AOR₂ = 4.06 [1.64–10.07]), LNG-EC (AOR₂ = 4.87 [3.88–6.10]), IUDs (AOR₂ = 21.08 [13.44–33.07]), and tubal sterilization (AOR₂ = 7.68 [1.69–34.80]) increased the risk of EP compared with the non-use of contraceptives.

Conclusion

Current use of most contraceptives reduce the risk of both IUP and EP. However, if the contraceptive method fails, the proportions of EP may be higher than those of non-users. In the case of contraceptive failure in the current cycle, EP cases should be differentiated according to current use of OCPs, LNG-EC, IUDs, and tubal sterilization. In addition, attention should be paid to women with previous long-term use of IUDs.

Should IVF be used as first-line treatment or as a last resort? A debate presented at the 2013 Canadian Fertility and Andrology Society meeting

Infertility outcomes can be influenced by many factors. Although a number of treatments are offered, deciding which one to use first is a controversial topic. Although IVF may have superior efficacy in achieving a live birth with a reasonable safety profile, the availability of cheaper and less invasive treatments preclude its absolute use. For this reason, certain patient groups with 'good-prognosis' infertility are traditionally treated with less invasive treatments first. 'Good-prognosis' infertility may include unexplained infertility, mild male factor infertility, stage I or II endometriosis, unilateral tubal blockage and diminished ovarian reserve. Here, evidence behind the use of IVF as a first-line treatment is compared with its use as a last-resort option in women with 'good-prognosis' infertility.

Female sterilization and refertilization

OBJECTIVE

To analyze data on sterilization and refertilization procedures that took place at Orbis Medical Center in Sittard, a hospital in the south of the Netherlands.

STUDY DESIGN

Retrospective cohort study of surgical tubal sterilizations performed on 966 patients for contraception between 2002 and 2011, and of 19 patients who underwent refertilization between 2002 and 2012. The main outcome measures were complications and failure rates of sterilization, motives for refertilization and pregnancy rates after refertilization. The t test and nonparametric tests were used to determine differences between groups and proportions.

RESULTS

Between 2002 and 2011, the number of sterilizations declined. Almost all the patients (99.8%) underwent laparoscopic sterilization. The most common method of sterilization used Filshie clips, and was used in 99.7% of the women. The median age at the time of sterilization was 37 years. The failure rate was 0.3%. All procedures were uneventful. The number of refertilizations during this time period also declined. The median time between sterilization and refertilization was 65 months. Patients who underwent refertilization were significantly younger at time of sterilization than patients who did not (p<0.001). After refertilization, 12 patients (63.2%) became pregnant.

CONCLUSIONS

The complication and failure rates of laparoscopic sterilization are low. The number of laparoscopic sterilizations and the number of refertilizations are both declining. Still, refertilization is a safe procedure and gives a significant chance of becoming pregnant.

Clinicopathological analysis of hepatocellular adenoma according to new bordeaux classification: report of eight korean cases

Background

Hepatocellular adenoma (HCA) is a rare benign tumor of the liver. A subtype classification of HCA (hepatocyte nuclear factor 1α [HNF1α]-mutated, β-catenin-mutated HCA, inflammatory HCA, and unclassified HCA) has recently been established based on a single institutional review of a HCA series by the Bordeaux group.

Methods

We used histologic and immunohistochemical parameters to classify and evaluate eight cases from our institution. We evaluated the new classification method and analyzed correlations between our results and those of other reports.

Results

Seven of our eight cases showed histologic and immunohistochemical results consistent with previous reports. However, one case showed overlapping histologic features, as previously described by the Bordeaux group. Four cases showed glutamine synthetase immunohistochemical staining inconsistent with their classification, indicating that glutamine synthetase staining may not be diagnostic for β-catenin-mutated HCA. HNF1α-mutated HCA may be indicated by the absence of liver fatty acid binding protein expression. Detection of amyloid A may indicate inflammatory HCA. HCA with no mutation in the HNF1α or β-catenin genes and no inflammatory protein expression is categorized as unclassified HCA.

Conclusions

Although the new classification is now generally accepted, validation through follow-up studies is necessary.

The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures

PURPOSE

The incidence of ectopic pregnancy (EP) in the general population is 2%, whereas the EP rate following assisted reproductive technologies (ART) is between 2.1 and 11%. EP is also an adverse effect of tubal surgery with incidences up to 40% depending on the type, location, and severity of tubal disease and the surgical procedure.

METHODS

This paper looks at the incidence of EP following tubal reconstructive microsurgery, analyzes risk factors for EP following own 1,295 ART cycles and looks on the incidence of EP in 128,314 pregnancies following ART according to the presence or absence of tubal infertility using data from the German IVF Registry (DIR).

RESULTS

In our clinic, the EP rate following resterilization was 6.7%. In the presence of acquired tubal disease, the EP rate following adhesiolysis, salpingostomy, salpingoneostomy, fimbrioplasty, and anastomosis was 7.9%. The EP rate following ART in our clinic was 5.6%. Previous abdominal surgeries, microsurgical procedures, hydro-/sactosalpinges, salpingitis, salpingitis isthmica nodosa, and periadnexal adhesions showed a significant positive correlation with EP as outcome. Data of DIR demonstrate a significantly increased incidence of EP in the presence of tubal pathology. The highest EP rate related to all clinical pregnancies was 4.5% (95% CI 3.0-6.0) in smoking women <30 years with tubal pathology following IVF.

CONCLUSIONS

In the presence of tubal infertility, the incidence of EP following ART and tubal microsurgery are approximately comparable with each other and higher than in women without tubal infertility. The success of infertility surgery depends on a careful selection of appropriate patients.

Tubal ligation regret and related risk factors: findings from a case-control study in Pernambuco State, Brazil

A case-control study was carried out at a public teaching hospital in Recife, Pernambuco State, Brazil in 1997 to investigate risk factors among women who feel regret after undergoing sterilization through tubal ligation. The study compared sterilized women who had requested or undergone a tubal reversal with women who were also sterilized but had not undergone this surgery, nor had requested to do so. Women showing a significantly greater probability of regret were those sterilized at a young age, those who had not themselves made the decision to undergo surgery , those for whom the sterilization was carried out up to the 45th day after childbirth and those who had acquired knowledge about contraceptive methods after the tubal ligation procedure. Having had a deceased child, a partner with no children prior to the current union or a change of partner after the tubal sterilization procedure were also associated to the request for or submission to tubal sterilization reversal. It is necessary to assess women's psycho-socio-demographic profiles, their reasons for requesting tubal ligation and to advise the patient about family planning in order to reduce rates of post-sterilization regret.

Infertility surgery is dead: only the obituary remains?

Despite the multiple advantages of assisted reproductive technology compared with surgery, there remain several diagnoses for which surgery is still widely performed: distal tubal occlusion, regret of permanent sterilization, and endometriosis. Assisted reproductive technology is superior to surgery and should be offered as first-line treatment.

Surgical competence of obstetrics and gynecology residents performing microsurgical tubal anastamoses

OBJECTIVE

To assess tubal patency rates after microsurgical tubal anastamosis in a residency program.

STUDY DESIGN

Retrospective cohort analysis. Primary outcome measurement was tubal patency rates.

RESULTS

Twenty-seven of the forty-nine patients (55.1%) had bilateral tubal patency and twenty-one of the forty-nine (42.9%) had only one tube open after surgery. No statistical difference in tubal patency rate was noted between the REI staff (85.7%) and the resident (71.4%) (p=0.09). No statistical difference was noted when comparing the patency rate of the residents' first procedure (68.6%) to subsequent procedures (72.8%) (p=0.99).

CONCLUSIONS

These data suggest that with appropriate guidance, residents without prior experience are able to perform microsurgical procedures under direct supervision. Residents completed the procedure with patency rates similar to the REI staff. Additionally, tubal patency rates were not significant different in comparing the residents' first or subsequent procedures.

Restoration of endocrine function and fertility with a tubo-ovarian autotransplant as the anatomical-functional unit in rabbits using a vascular microsurgical technique

Infertility has been considered a global public health problem in many countries worldwide. Our objective was to restore endocrine function and fertility in tubal-oophorectomized rabbits using an orthotopic tubal-ovarian vascularized autotransplant model as the anatomical-functional unit while employing a microvascular surgical technique. Twenty New Zealand white (NZW) sexually mature female rabbits and four male NZW rabbits of proven fertility were divided into two study groups. In group I (n = 10), a left salpingo-oophorectomy was performed. Group II (n = 10) was subjected to a bilateral salpingo-oophorectomy, plus a right orthotopic tubal-ovarian autotransplant. Our testing variables were vascular and tubal-anastomoses permeability, estradiol (E2) and progesterone (P4) serum levels, pregnancy, number of offspring, histopathological study of the uteri, fallopian tubes, and ovaries. One hundred percent immediate permeability of the tubal anastomoses was achieved, while late permeability was found to be 64%. Immediate permeability of vascular anastomoses was 90%, and late permeability was recorded at 80%. E2 serum levels in both groups at different times showed no statistically significant differences. In the case of P4, a small difference was found during pregnancy, especially greater in the control group (P < .05). In the autotransplanted group, four rabbits became pregnant (44%). Endocrine function and fertility were restored in the rabbits with the tubal-ovarian transplant as the anatomical-functional unit. The use of isotransplants and allotransplants should be considered a therapeutic alternative in the infertile woman with irreparable bilateral tubal damage, ovarian dysgenesis, surgical absence of ovaries and fallopian tubes, or when the conventional IVF/TE in these cases has been unsuccessful.

Identifying women who will request sterilization reversal in a military population

OBJECTIVE

We sought to identify the characteristics of women in a military population who are likely to seek a tubal anastomosis after a previous bilateral tubal ligation (BTL).

METHOD

A written investigational review board-approved questionnaire was administered to 56 women, ages 18-40 years, requesting evaluation for a reversal of a prior BTL and 52 women of the same age range not seeking reversal. The questionnaire identified demographics and relationship characteristics of volunteers at the time of their decision to have a BTL and at the present time.

RESULTS

Age 25 years or younger, sterilization due to pressure from a partner, poor marital relationship at the time of the BTL and a new marriage are highly predictive of tubal sterilization regret and a request for sterilization reversal in a military population. In addition, women requesting a tubal anastomosis reported less preoperative counseling on the permanence of a BTL and of the male alternative for permanent female sterilization, vasectomy.

CONCLUSION

Women with these characteristics should have extensive counseling before undergoing tubal sterilization.

Changes in family structure and regret following tubal sterilization

Tubal sterilization is one of the contraceptive methods whose use has increased the most in Brazil, but a growing number of women have expressed regret after the procedure. A case-control study was conducted at the Centro Integrado de Saúde Amaury de Medeiros (CISAM), Recife, Pernambuco, Brazil, in 1997 to investigate the association between changes in family structure and request for or submittal to surgical reversal of tubal sterilization, comparing 304 sterilized women who had requested or submitted to reversal of tubal sterilization and 304 women who were also sterilized but had not requested, had not submitted to, and who did not wish to submit to reversal. The simple and adjusted odds ratios were estimated using logistic regression. The results of the current study showed that death of children, partners without children prior to the current union, and partner change after tubal sterilization were associated with the request for or submittal to reversal of tubal sterilization. More strict criteria are suggested in the indication of tubal sterilization, including an in-depth profile of the woman requesting tubal sterilization and identification of risk factors for future regret.

Sutureless re-anastomosis by laparoscopy versus microsurgical re-anastomosis by laparotomy for sterilization reversal: a matched cohort study*

BACKGROUND

Sutureless re-anastomosis per laparoscopy is an alternative for microsurgical re-anastomosis by laparotomy in the treatment of sterilized women with renewed child wish. Our aim was to compare pregnancy rates after both surgical techniques.

METHODS

We performed a retrospective cohort study in which consecutive women who underwent sutureless re-anastomosis per laparoscopy were compared to women who underwent microsurgical re-anastomosis by laparotomy. Both procedures were performed in neighbouring hospitals in Northern-Brabant, The Netherlands, and women were matched for age. The primary outcome was time to ongoing pregnancy.

RESULTS

Overall, we included 41 women who had sutureless re-anastomosis by laparoscopy, and 41 age-matched women who underwent microsurgical re-anastomosis by laparotomy. The number of women who conceived was 20 (15 ongoing pregnancies) in the sutureless laparoscopic group versus 26 (24 ongoing pregnancies) in the laparotomic group, a difference due to a longer follow-up period in the laparotomic group. Time to ongoing pregnancy was comparable in both groups (P=0.46), with 3 year cumulative ongoing pregnancy rates of 45 and 52% respectively. After adjustment for other prognostic factors, the fecundity rate ratio was 0.97 (95% CI 0.26-3.6), indicating a similar performance of the two techniques.

CONCLUSION

The simplified stitchless laparoscopic procedure for reversal of tubal sterilization with the use of a tubal splint, clip fixation of the muscularis and fibrin glue resulted in a promising pregnancy rate, which was similar to the pregnancy rate obtained with the microsurgical re-anastomosis per laparotomy.

Factors affecting the pregnancy rate after microsurgical reversal of tubal ligation

OBJECTIVE

To evaluate the factors affecting the pregnancy rate after microsurgical reversal of tubal ligation.

DESIGN

Retrospective clinical study.

SETTING

Private practice affiliated with a tertiary care center. One hundred twenty-eight consecutive patients who underwent tubal reversal between October 1992 and May 2001.

INTERVENTION(S)

Microsurgical tubal reanastomosis performed by a single surgeon.

MAIN OUTCOME MEASURE(S)

Subsequent pregnancy rates were evaluated with Fisher's exact tests and logistic regression according to clinical characteristics of patients.

RESULT(S)

The pregnancy rate was 85.7% (54 out of 63) in patients <or=35 years of age vs. 45.5% (10 out of 22) in patients >35 years. The odds ratio (OR) between the two age groups was 7.20, with a 95% confidence interval (CI) of 2.41 to 21.55. The pregnancy rate was 85.4% (35 out of 41) in patients with body mass index (BMI) <or=25 compared with 65.9% (29 out of 44) in patients with BMI >25 (OR 3.02; CI 1.04 to 8.77). Patients sterilized <or=8 years had a pregnancy rate of 87.2% (34 out of 39), vs. 65.2% (30 out of 46) in patients sterilized >8 years (OR 3.63; CI 1.19 to 11.09).

CONCLUSION(S)

Age was the primary statistically significant factor affecting pregnancy rate in tubal reversal patients. Body mass index and duration of sterilization had smaller, but statistically significant, associations with pregnancy rate.

Surgical intervention in infertility management

Despite improvement in the success of IVF, reproductive surgery will remain an important option and complement to assisted reproductive technologies (ART) for many couples. Reproductive surgery should be considered as the first-line treatment when the correction of infertility pathologies is simple and a good result is expected once corrected, when the pathology is causing symptoms such as pain or abnormal bleeding, or if uncorrected will compromise the results or increase the risks of ART. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialized reproductive and general gynaecological surgery it is crucial to follow microsurgical principles to avoid adhesion formation and conserve normal tissues, especially tubal and ovarian. These aspects of reproductive surgery, and different surgical techniques used for various tubal, peritoneal, uterine and ovarian conditions to achieve the optimal reproductive outcome are discussed in this article.

An unusual complication of tubal anastomosis

OBJECTIVE

To report an unusual complication associated with the use of a long-term intrafallopian stent during microsurgical tubal anastomosis.

DESIGN

Case report.

SETTING

Tertiary academic center.

PATIENT(S)

A 36-year-old woman in whom an intrafallopian stent used during a sterilization reversal procedure could not be transcervically retrieved in the office.

INTERVENTION(S)

Hysteroscopic evaluation for removal of intrafallopian stent, followed by operative laparoscopy for postoperative abdominal pain.

MAIN OUTCOME MEASURE(S)

Patient symptoms, potential for morbidity, and review of the literature.

RESULT(S)

Hysteroscopic view of the uterine cavity failed to identify the intrafallopian stent. Laporoscopic evaluation of postoperative abdominal pain revealed significant formation of pelvic and abdominal adhesions. The 2-0 nylon suture used as an intrafallopian stent was seen sitting freely on top of the liver serosa. Adhesiolysis and successful retrieval of the stent resolved the patient's symptoms.

CONCLUSION(S)

To our knowledge, this is the first report describing complete dislodgment and cephalad migration of an intrafallopian stent. Patient morbidity and health care costs may increase when long-term stents are used for sterilization reversal.

Fertility outcomes following laparoscopic tubal re-anastomosis post tubal sterilisation

OBJECTIVE

To determine fertility outcomes following laparoscopic tubal re-anastomosis.

DESIGN

Retrospective mail follow-up.

SETTING

Specialised private gynaecological endoscopy practice.

POPULATION OR SAMPLE

19 women who underwent laparoscopic tubal reanastomosis following tubal sterilisation.

MAIN OUTCOME MEASURES

Pregnancy rate and 'take home baby' rate.

RESULTS

15 (78.9%) of women became pregnant, and 13 (68.4%) carried pregnancies to viability. The mean operating time was 115 minutes (range 90-200 minutes). The mean reversal to pregnancy interval was 8.3 months (1-24 months).

CONCLUSIONS

This study suggests that the pregnancy and 'take home baby' rates after laparoscopic reversal of tubal sterilisation compare favourably with open microsurgical reversal and in vitro fertilisation.

IVF following impossible or failed surgical reversal of tubal sterilization

Microsurgical re-anastomosis or IVF offer ways of reversing previous tubal sterilization. This retrospective study analysed 56 attempts of IVF in 37 couples after impossible or failed surgical sterilization reversal. Efficacy of IVF in this group (TL) was compared with that of a tubal pathology control group (TP) at all stages of IVF (stimulation, fertilization and implantation). Depending on patient age, significantly fewer oocytes were produced after ovarian stimulation in the TL group than in the control (TP) group (P = 0.023 for all TL patients; P = 0.02 when patients aged >38 years were excluded). The total number of embryos available for transfer was significantly lower in the TL group (P = 0.0042), but this was age-related, since when women aged >38 years were excluded there was no significant difference between the two groups. The ongoing pregnancy rate was similar in both groups, the probability of ongoing pregnancy appearing to depend on patient age rather than on previous fertility.

Laparoscopic tubal anastomosis: fertility outcome in 202 cases

OBJECTIVE

To evaluate the fertility outcome after laparoscopic tubal anastomosis for reversal of sterilization.

DESIGN

Retrospective clinical study.

SETTING

A private practice affiliated with a university medical school.

PATIENT(S)

Two hundred two women who desired reversal of tubal sterilization.

INTERVENTION(S)

Laparoscopic tubal anastomosis.

MAIN OUTCOME MEASURE(S)

The cumulative pregnancy rate (PR) and factors that influenced the fertility outcome.

RESULT(S)

The cumulative PR in the 186 patients for whom follow-up data were available was 60.3%, 79.4%, and 83.3% at 6, 12, and 18 months after operation, respectively. Five patients (3.2%) had ectopic pregnancies; one of these patients subsequently conceived normally. There were no statistically significant differences in the PR according to the sterilization method used, the site of the tubal anastomosis, or the length of the fallopian tube after surgery. The intrauterine PR was 87.1% (149/171) with bilateral anastomosis and 60% (9/15) with unilateral anastomosis. The PR decreased with increasing patient age (mean [+/- SD], 35+/-3.6 years) but was still 70.6% (12/17) in patients aged 40-45 years.

CONCLUSION(S)

Our findings suggest that laparoscopic tubal anastomosis is a highly successful procedure. This less invasive approach could be considered the procedure of choice in patients who desire reversal of tubal sterilization.

Single suture laparoscopic tubal re-anastomosis

The goal of this article is to report our experience and review recent articles obtained for laparoscopic tubal sterilization reversal. The technique we describe is 'single suture laparoscopic tubal re-anastomosis'. This technique is simple and atraumatic and requires only one stitch in the tube. After preparing the tube stumps and bringing the edges of the mesosalpinx together, laparoscopic anastomosis is achieved by one stitch placed at '12 o'clock' on the antimesial edge of the tube. Between May 1994 and June 1997 we operated on 32 patients using this technique and carried out 48 tubal sterilization reversals. For the patients who underwent postoperative hysterosalpingography during the first or second month after the operation, the rate of patency was 87.5% (42/48). The overall intrauterine pregnancy rate was 53.1% (17 out of 32 patients). The overall delivery rate was 40.6% (13 out of 32 patients). The intrauterine pregnancy rate for the 17 patients who were aged 38 years or under was 58.8% (10 out of 17 patients). Laparoscopic tubal sterilization reversal is feasible with a simplified technique. Review of the publications concerning laparoscopic microsurgical tubal anastomosis confirms satisfactory fertility results. The surgeon should be experienced in microsurgical tubal anastomosis by laparotomy as well as operative laparoscopic procedures.