|ORIGINAL CONTRIBUTION - FERTILITY CLINICS IN GYNECOLOGICAL SURGERY
|Year : 2016 | Volume
| Issue : 2 | Page : 82-85
Reversal surgeries in patients with female sterilization: A retrospective analysis of diverse approaches over a 10-year period
Vijayan Chandrathil Parameswaran Nair, Bessy Binu Sam, R Beenakumary
Department of Obstetrics and Gynaecology, Government Medical College, Kottayam, Kerala, India
|Date of Web Publication||30-Dec-2016|
Vijayan Chandrathil Parameswaran Nair
Government Medical College, Narayaneeyam, Gandhinagar P.O, Kottayam - 686 008, Kerala
Source of Support: None, Conflict of Interest: None
Objectives: To analyze the results of diverse surgical approaches performed for reversal of female sterilization and to understand the possible impact of primary host factors which may contribute to a successful outcome. Method: A retrospective analysis was performed on all patients who submitted themselves for a surgical reversal of female sterilization in a tertiary care teaching hospital over a 10-year period from 2002 to 2012. Setting: Department of Obstetrics and Gynecology, Government Medical College Hospital Kottayam, Kerala, South India. Results: A total of 69 surgical procedures were carried out for reversal of female sterilization. Of them, following surgery, 29 (42%) had intrauterine pregnancies. Of these, 3 (4%) aborted, 9 (13%) suffered an ectopic pregnancy, while the "successful take home baby rate" was 37%. A total of 31 women were lost to follow up. Conclusions: Reversal surgeries have a fair rate of success in women who have had sterilization, though the success rate varies with the surgical approach, the age of the woman, and the technique adopted during the course of female sterilization. It may be best if female sterilization procedures were to be restricted to the isthmus with minimal damage to the fallopian tubes.
Keywords: Female sterilization, isthmus, reversal
|How to cite this article:|
Nair VC, Sam BB, Beenakumary R. Reversal surgeries in patients with female sterilization: A retrospective analysis of diverse approaches over a 10-year period. Astrocyte 2016;3:82-5
|How to cite this URL:|
Nair VC, Sam BB, Beenakumary R. Reversal surgeries in patients with female sterilization: A retrospective analysis of diverse approaches over a 10-year period. Astrocyte [serial online] 2016 [cited 2019 Jun 15];3:82-5. Available from: http://www.astrocyte.in/text.asp?2016/3/2/82/197211
| Introduction|| |
Of the various permanent population control methods practiced in the country, female sterilization is the most common. Two approaches are in vogue: (a) Postpartum sterilization and (b) Interval sterilization. Several techniques have been defined to achieve the goal. However, due to changed personal circumstances, many women who undergo sterilization are compelled to seek restoration of fertility. Reasons may vary and include loss of one or more child, remarriage, and societal pressures to bear a male heir. Often such women are referred for assisted reproductive techniques (ART), which involve high financial and emotional cost, are not universally accessible, and do not necessarily result in a favorable outcome. These women may stand better benefited with recanalization surgery, which requires a deft surgical hand, but does not depend on high cost technology necessary for ART. The results of this reversal surgery however may relate to a number of factors, including the age of the patient, method followed for sterilization, and the procedure performed for reversal. This study dwells on these variables to determine the factors associated with favorable results.
| Materials and Methods|| |
This study analyses the data relating to a total of 69 surgical recanalizations carried out during a ten year period between 2002 and 2012 at the Kottayam Government Medical College Hospital.
When a woman approaches this center for reversal of sterilization, reason is assessed. In case of remarriage male partner is assessed first for infertility. If male cause of infertility is diagnosed then reversal surgery of woman is deferred. During the initial half of the study a preliminary laparoscopy was done in all women to find out the type of sterilization, to assess the available length of the tube. Women with absent fimbrial end and short length of remaining tube diagnosed on laparoscopy were directed for in vitro fertilization (IVF). As none of them opted for IVF, we were forced to try out reversal surgery in them. During the later half of the study preliminary laparoscopy was avoided, and if sterilization details were not available, patients were counseled as per various possibilities.
Reasons for performing various procedures for recanalization were following:
All procedures were done through laparotomy route in the conventional macroscopic method.
- If the previous sterilization procedure had been done at the isthmus portion (falope clip application or ligation), an isthmio-isthmial anastomosis was performed.
- In case the blockage was at the junction of the isthmus and ampulla, isthmio-ampullary anastomosis was performed.
- If the blockage was close to the cornua with medial stump of the tube not being available and the distal end of the tube being 6 cm or more in length, an uterotubal reimplantation was done.
- If the fimbrial end of the tube was absent (after lateral salpingectomy), a neofimbrioplasty was attempted.
All patients received perioperative antibiotics and adhesion prevention measures were adapted to the extent possible. , All of them were subjected for hydrotubation after one menstrual cycle.
- End-to-end anastomosis (both isthmio-isthmial and isthmio-ampullary): The cut ends were trimmed and the sprouting mucosa was identified. The patency of both ends was checked by injecting saline. The ends of the tubes were brought together and the mesosalpinx was sutured first. The seromuscular layers were sutured together excluding the mucosa using 3-0 or 4-0 synthetic absorbable suture materials. Four to six sutures were put to cover the entire circumference of the tube. Microscope was not used
- Uterotubal reimplantation: When the medial stump of the tube was practically absent for trimming and the distal end is long, i.e., more than 6 cm, this was the procedure done. Vasopressin was injected to the posterior surface of the uterus, and a transverse incision was made there in between the insertion of ovarian ligaments just below the line connecting them. Both the tubes were implanted through either end of this incision, and uterine incision was closed taking care to avoid compression on the tubes
- Neofimbrioplasty: When both the fimbriae were absent, the distal end of the tube was split into two or three longitudinally for 5-6 mm and the mucosa was reverted and sutured to the serosa. Patency was ensured.
| Results|| |
In all sixty-nine reversal surgeries were carried out over the 10 years period. Results of reversal surgeries are given in [Table 1].
|Table 1: Outcome of Diverse Reversal Surgeries for Fertility Restoration in Previously Sterilized Women |
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Twenty-nine women had conceived till the time of reporting. Only the first conception of the individual was included in the analysis [Table 1].
Subsequent conceptions occurred in many women. Three women underwent retubectomy later.
Age distribution of the individuals who underwent reversal surgery is given in [Table 2].
The success rate of reversal following different types of sterilization methods is described in [Table 3].
| Discussion|| |
The overall conception rate in this series was 42% (29/69); 62% of the total conceptions occurred during the 1 st year and 38% occurred after 1 year but within 3 years of surgery. Bhatla  reported that the average conception rate in conventional macroscopic method was 50%. Jindal et al.  reported 60% success rate, and according to that study, the results of macroscopic method were better than microscopic method. In this series, there were three abortions (10% of total conceptions) and nine ectopic pregnancies (13% of total reversal surgeries). The incidence of abortions and ectopic pregnancies varied in different studies.
Apart from expertise of the surgeon and quality of surgical environment and materials available, important factors deciding the success of reversal surgeries are the site of reversal done, length of the reaming tube after reversal surgery, age of the individual at the time of reversal, and type of the previous sterilization technique. The site of reversal done and the length of the remaining tube are related. Similarly, the site of previous sterilization operation also determines the length of the remaining tube. In this recanalization series isthmio-isthmial anastomosiss, done on both sides, had the best results with a success rate of 55.5%. Uterotubal reimplantation has the next best rate of 54%. When isthmio-isthmial anastomosis was done on one side and isthmio-ampullary anastomosis on the other side, the success rate dropped to 42%. Bilateral isthmio-ampullary anastomosis had the lowest rate at 27%. Isthmus of the tube is considered as an ideal site for sterilization, considering the need for its reversal. 
Jindal et al.  reported a success rate of 80% for bilateral isthmio-isthmial anastomosis and 50% success for bilateral isthmio-ampullary anastomosis. Spare et al.  reported 55% success for isthmio-isthmial anastomosis and 40% success for isthmio-ampullary anastomosis. Neofimbrioplasty was not at all successful, and only one woman conceived from that group of 11 and that too resulted in abortion. One had an ectopic pregnancy. None of them had a live baby.
In this series, the maximum success rate was seen in the age group of 20-24 years (62.5%) and the least in the age group of 35 years and above (17%). This shows that success rate of reversal of sterilization decreased as the age of woman advances. This is in accordance with other studies. ,,
The method of sterilization is another important factor which decides the success rate following recanalization. If the method of sterilization had been laparoscopic falope ring application, the success rate was highest at 75% for postabortal laparoscopy, at 54.5% for interval laparoscopy and overall success rate being 60%. The pregnancy rate of reversal after laparoscopic tubal occlusion reported by Jindal et al.  was 62.5%. If the previous sterilization was postpartum, the success rate was the lowest at 32%. While sterilization done concurrent with LSCS had a success rate of 44%.
At the turn of this millennium, some of the practitioners were of the opinion that tubal corrective surgeries were obsolete in this era of artificial reproductive technologies. The practice committee of the American Society for Reproductive Medicine has come out with its recommendations for the role of tubal surgery which is slightly different from its own recommendations in 2012.  The recommendations as such may not be applicable to resource-poor settings, but it shows that the American Fertility Society accepts the tubal recanalization surgeries. In May 2016, Berger et al.  reported a large series of bilateral tubo-tubal anastomosis. They reported overall pregnancy rate of 69% and birth rate of 35% among 6692 women. In their opinion also, birth rate declined as the age at reversal increased and the best results are for the reversal of tubal rings or clips.
Even though not included in this series, laparoscopic nonmicrosurgical reanastomosis is another option for reversal of tubal occlusion. It requires laparoscopic surgical equipment and expertise which may not be that freely available in all parts of India and other resource-poor settings. Robotic tubal occlusion reversal is another option. Jayakrishnan and Baheti  reported a success rate of 85.7% for laparoscopic tubal reanastomosis, following laparoscopy sterilization and 40% success rate following Pomeroy method. Ribeiro et al.  reported a success rate of 56.5% for laparoscopic tubal reanastomosis. The FIGO Educational Platform Report 2016 states that during the learning curve period, the success rate for the laparoscopic reversal may be lower and overall success rate may not be altered from that of open method.  Hence, in general, open surgical method is acceptable as a low-technology alternative to IVF for women who wish to conceive after tubal sterilization.
| Conclusions|| |
Commensurate with the increase in number of female sterilizations, the demands for its reversals have also arisen. Surgical reversal of female sterilization definitely has a role when need for conception arises post sterilization. It is worth attempting in women who refuse assisted reproductive techniques and in resource poor settings Even in an ordinary setting, the overall success rate is near 50% and take-home baby rate near 37% and this may be amenable for betterment in more favorable circumstances. If sterilization is performed by lateral salpingectomy, the reversal option is only neofimbrioplasty and its success is negligible hence this procedure may be abandoned. Preliminary assessment using laparoscopy and counseling is advisable.
Success rate of reversal of female sterilization decreases as age of the woman advances. Beyond 35 years, the success rate falls considerably and the couple should be counseled about this. Some of them may opt for assisted reproductive techniques decide to immediately with comparable results. 
The limitations of IVF in our population, such as the cost, and availability, need to be considered but the final decision must rest with the couple.
A surgeon while performing a female sterilization procedure must be aware of a possible need that the procedure might require a reversal sometime in the future and from this perspective, should exercise at least two safeguards: one, the tubes should be blocked at the isthmus; and two, care should be taken that a minimum length of the tube is left. These simple safeguards can contribute most significantly to the success of female sterilization reversal surgery and restore fertility in women who wish to retrace their decision for one or the other family reason.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]