Tubal reversal

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Tubal reversal - short for tubal sterilization reversal or tubal ligation reversal - is a surgical procedure that restores fertility to women after a tubal ligation. By rejoining the separated segments of fallopian tube, tubal reversal gives women the chance to become pregnant again naturally. This delicate surgery is best performed by a reproductive surgeon with specialized training and experience in the techniques of tubal ligation reversal.

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[edit] Tubal anatomy

To understand the techniques of tubal reversal surgery, it is helpful to visualize the anatomy of the normal fallopian tube[1]. The fallopian tube is a muscular organ extending from the uterus and ending next to the ovary. The tube is attached to the ovary by a small ligament. The inner tubal lining is rich in cilia. These are microscopic hair-like projections that beat in waves that help move the egg or ovum to the uterus in conjunction with muscular contractions of the tube.

Fallopian Tube Anatomy
Fallopian Tube Anatomy

The fallopian tube is normally about 10 cm (4 inches) long and consists of several segments. Starting from the uterus and proceeding outward, these are the:

  • Interstitial segment - extends from the uterine cavity through the uterine muscle
  • Isthmic segment - narrow muscular portion adjacent to the uterus
  • Ampullary segment - wider and longer middle part of the tube
  • Infundibular segment - funnel shaped segment next to the fimbrial end
  • Fimbrial segment - wide opening at the end of the tube facing the ovary

[edit] Tubal reversal procedures

[edit] Microsurgery

Tubal ligation reversal utilizes the techniques of microsurgery to open and reconnect the fallopian tube segments that remain after a tubal sterilization procedure. Microsurgery minimizes tissue damage and bleeding during surgery. Essential elements of microsurgical technique include gentle tissue handling, magnifying the operating field, keeping body tissues in their normal state with warmed irrigation fluids, and using the smallest sutures with the thinnest needles capable of holding the tubal ends together to promote proper healing of the rejoined tubal segments.

[edit] Tubotubal anastomosis

Following a tubal ligation, there are usually two remaining fallopian tube segments - the proximal tubal segment that emerges from the uterus and the distal tubal segment that ends with the fimbria next to the ovary. After opening the blocked ends of the remaining tubal segments, a narrow flexible stent is gently threaded through their inner cavities or lumens and into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes (mesosalpinx). The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscular portion (muscularis externa) and outer layer (serosa), while avoiding the inner layer (mucosa) of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.

[edit] Tubouterine implantation

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal segment. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubouterine implantation, uterotubal implantation, or, simply, tubal implantation. Tubal implantation is performed when tubal anastomosis is not possible due to the absence of a proximal tubal segment and interstitial tubal lumen.

[edit] Ampullary salpingostomy

Fimbriectomy is an uncommon type of tubal ligation that is performed by removing the fimbrial portion of the fallopian tube next to the ovary, leaving the tubal segment attached to the uterus. After fimbriectomy, the remaining tubal segment can be opened by the technique ampullary salpingostomy[2]. A microsurgical electrode is used to open the tubal end and expose the internal lining. When the opening has been enlarged sufficiently and the internal lining or endothelium has extruded from the tubal end, sutures are placed to keep the endothelium folded outward over the edge and to prevent the tube from closing again.

[edit] Mini-laparotomy tubal reversal

Mini-laparotomy for tubal reversal surgery involves making a small incision in the abdominal wall just above the pubic bone after shaving the hair with a sterile hair clipper. The size and location of the incision as well as the plastic surgery techniques used to close it make the hair-line scar invisible when it has healed. Atraumatic surgical techniques developed by Dr. Berger involve the use of local anesthesia at the incision site and other tissues operated upon. This makes the surgery comfortable and minimizes post-operative pain. As opposed to standard operative methods, avoiding the use of surgical retractors and packs, constantly irrigating tissues to keep them moist and at body temperature, and operating under magnification throughout the procedure results in very rapid patient recovery. Operating with microsurgical instruments allows precision in suturing of the tubal segments than is possible with longer needle holders and other instruments such as are used in laparoscopic surgery. In the experience of a tubal reversal doctor who has performed more than 7000 outpatient reversal procedures, this is the preferred method of minimally invasive surgery for tubal ligation reversal.

[edit] Laparoscopic tubal reversal

Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure (laparoscopy), using small, specially-designed instruments to repair and reconnect the fallopian tubes.

After general anesthesia has been administered, a 10mm (less than ½-inch) tube (trocar)is inserted just at the lower edge of the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The laparoscope (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than ¼-inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.

One technique involves the use of a tubal cannulator, which is inserted into the uterus through the cervix, allowing the tube to be threaded with a fine stent. This allows for improved alignment of the tubes, so a much better connection can be accomplished.[3] Tiny sutures (less than a hair in thickness) are carefully and meticulously placed to connect the two segments.

Once the connection (anastomosis) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well.

All instruments are removed, the gas is extracted from the abdomen, and the patient is awakened and taken to the recovery room to be watched and cared for by the nurses, as well as by the anesthesiologist who makes sure the patient is comfortable and without pain. On the average, two to four hours later most patients are ready to be discharged.

Patients are seen between 5-7 days after the operation to look at the small incisions and remove any stitches if necessary. Most of the time, the few stitches that were placed will be under the skin and will be absorbed by the body, without need for removal.

Patients should wait two to three months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of ectopic pregnancy (pregnancy inside the fallopian tube instead of in the uterus).

When performed by a trained laparoscopic or outpatient tubal reversal surgeon, laparoscopic or outpatient mini-laparotomy tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery – namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars.[4]

[edit] Reasons for tubal reversal

Women give many reasons for having a tubal ligation reversal. One of the questions that Dr. Berger asks his patients is “What made you decide to have a tubal reversal procedure at this time?” The most common responses to this question are:

  • Remarriage with desire to have children with new spouse (75%)
  • Same marriage with desire to have more children (20%)
  • Death of a child (2%)
  • Relief of symptoms of "Post Tubal Ligation Syndrome" (2%)
  • Religious or spiritual concerns

[edit] Sterilization regret

In a study called the U.S. Collaborative Review of Sterilization (CREST) , women who had tubal ligations were asked "Do you still think tubal sterilization as a permanent method of birth control was a good choice for you?" Overall, 13% of women said they did not think that the tubal ligation was a good choice. The percentage expressing regret was 20% for women aged 30 years or younger at the time of sterilization, compared with 6% for women older than 30 years at the time of tubal ligation. For women under age 25, the rate was 40%.

Despite the high percentage of women who subsequently regret having had a tubal ligation, only 0.2% of women in the CREST study underwent tubal reversal. Reasons for this discrepancy may include lack of information about tubal reversal, cost of the procedure, and lack of insurance coverage for this procedure. Women often receive inaccurate information about tubal reversal - such as tubal ligation cannot be reversed, or the only treatment option is in vitro fertilization (IVF), or tubal reversal is available only as a high cost operation requiring hospitalization.

[edit] References

  1. ^ Berger, G.S. "Anatomy of the Fallopian Tube" Chapel Hill Tubal Reversal Center. 2008.Retrieved 04/05/2008 _ http://www.tubal-reversal.net/tubal_ligation_fallopian_tube.htm
  2. ^ Berger, G.S. "Microsurgical Salpingostomy" Chapel Hill Tubal Reversal Center. 2008.Retrieved 04/06/2008 _ http://www.tubal-reversal.net/salpingostomy.htm
  3. ^ Rotman C., Rana N., Song, J., Sueldo, C.: Simplification of Laparoscopic Tubal Reversal by Using a Tubal Cannulator. Fertility and Sterility, Vol. 88, Supp. 1, Page S109, September 2007.
  4. ^ Rotman C., Rana N., Song J., Sueldo C. Chapter - Laparoscopic Tubal Anastomosis. Textbook of Infertility and Reproduction. Cambridge University Press. 2007.

[edit] External links