Tubal reversal, also called tubal sterilization reversal, tubal ligation reversal, or microsurgical tubal reanastomosis, is a surgical procedure that can restore fertility to women after a tubal ligation. By rejoining the separated segments of the fallopian tube, tubal reversal can give women the chance to become pregnant again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be re-implanted into the uterus (a 'tubal reimplantation'). In other cases, when the end of the tube (the 'fimbria') has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation.
The fallopian tube is a muscular tube extending from the uterus and ending with attached fimbria next to the ovary. The tube is attached to the ovary by a thin tissue called the mesosalpinx. The inner tubal lining is lined with cilia. These are microscopic hair-like projections that beat in waves that push fluid down the tube towards the uterus thereby helping move the egg or ovum to the uterus in conjunction with muscular contractions of the tube. The fallopian tube is normally about 10cm (4inches) long and consists of several regions that become wider as the tube gets farther away from the uterus. Starting from the uterus and proceeding outward, these are the:
Interstitial region - extends from the uterine cavity through the uterine muscle
Isthmic region - narrow muscular portion adjacent to the uterus
Ampullary region - wider and longer middle part of the tube
Infundibular region - funnel shaped segment next to the fimbrial end
Fimbrial region - wide opening at the end of the tube that is responsible for 'catching' the egg after it is released from the ovary during ovulation
Tubal reversal surgeries
Tubal reversal surgeries require the techniques of microsurgery to open and reconnect the fallopian tube segments that remain after a tubal sterilization, reimplant remaining segments, or create new fimbria.[1][2]
Following a tubal ligation, there are usually two remaining fallopian tube segments - the proximal (close) tubal segment that emerges from the uterus and the distal (far) tubal segment that ends with the fimbria next to the ovary. After opening the blocked ends of the remaining tubal segments, a variety of microsurgical techniques are utilized to recreate a functional tube. The newly created tubal openings are drawn next to each other by placing sutures in the connective tissue that lies beneath the fallopian tubes (mesosalpinx). The retention suture prevents the tubal segments from pulling apart while the tube heals. Microsurgical sutures are used to precisely align the tubal lumens (inside canal of tube), the muscular portion (muscularis externa), and the outer layer (serosa) of the tube. Most surgeons try to avoid the use of stents which can damage the delicate cilia that line the tube and create the flow of fluid that is needed to push the egg and embryo into the uterus. Other surgeons use a narrow flexible stent to gently thread through the tubal segments or into the uterine cavity in order to line up the tubes in order to reconnect them. In either case, once the microsurgical repair is completed dye is injected through the cervix into the uterus and out through the tubes to ensure that the fallopian tube is open from the uterine cavity to its fimbrial end. The surgeons who use stents then gently withdraw them from the fimbrial end of the tube after the repair is completed.
Tubal Reimplantation
In a small percentage of cases, a tubal ligation procedure leaves only the distal (far) portion of the fallopian tube and no proximal (close) tubal segment. This can occur when any method of tubal ligation 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 tubal reimplantation.
Neofimbrioplasty
Fimbriectomy is a very uncommon type of tubal ligation that is performed by removing the end (fimbria) of the fallopian tube leaving only the tubal segment attached to the uterus. After fimbriectomy, if the remaining tubal segment is long enough, the end of the tube can be opened and 'new' fimbria can be created by a procedure called a neofimbrioplasty. These "new" fimbria are not actually fimbria, but they are the cilia from the inside of the fallopian tube that have been exposed by everting the tubal lumen much like the petals of a rose are exposed once the rose blooms. These 'new' fimbria are much less effective at collecting (catching) an egg that has been released from the ovary than the real fimbria that had been removed during the fimbriectomy performed by the surgeon who did the original tubal ligation. During a neofimbrioplasty the tubal end is opened and folded back (marsupialized) so that the tubal end remains open and exposing the internal lining of the tube.
Mini-laparotomy tubal reversal
Mini-laparotomy for tubal reversal surgery involves making a small, 2 to 3 inch 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 thin scar nearly invisible after it has healed. Atraumatic surgical techniques 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.
Microsurgical Tubal Reanastomosis (MTR)
In this Process, The area of the tubes which was occluded is removed, leaving only open, healthy tube. These open, healthy, tubal segments are then connected. A multi layer, micro surgical technique is used to suture these segments together. After the tubes are repaired, a chromopertubation is performed wherein dye is injected into the uterus. This dye is passed through the repaired tubes to ensure that the tubes are open. The entire surgery is performed through a small incision of about 3 to 4 inches just at the uppermost part of the hair line. It is very important to note that either failing to properly align the tubal segments, or damaging these delicate structures, can make the difference between a successful and an unsuccessful operation.[3]
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 5mm (less than 3/8-inch) tube (trocar) is inserted inside 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 fallopian tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than 1⁄4-inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.
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.
Patients are sent home the same day of surgery. The few stitches that are placed will be under the skin and will be absorbed by the body, without need for removal.
Patients should wait two 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 tubal reversal surgeon, laparoscopic 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] Laparoscopic surgery can be more expensive than an open surgery using a 2 to 3 inch incision because it requires additional surgical equipment.
Robotic assisted tubal reversal
Robotic assisted tubal reversal surgery is a surgical procedure in which the fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system.
The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.
Robotic tubal ligation reversal uses the same small incisions as a traditional laparotomy tubal reversal surgery. Smaller incisions generally result in less pain and quicker return to work when compared to traditional tubal ligation reversal using larger abdominal incisions. The robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal, but not as much dexterity as with an open procedure using a 2 to 3 inch incision. The disadvantages to robotic surgery are longer operating times and much higher costs than even traditional laparoscopic surgery.
A retrospective, Cleveland Clinic study compared 26 patients who underwent robotic assisted tubal reversal to 41 patients who underwent outpatient mini-laparotomy (abdominal incision) tubal reversal. Robotic tubal reversal patients, when compared to abdominal tubal reversal surgery patients, had longer times under anesthesia (283 minutes vs 205 minutes) and longer times in surgery (229 minutes vs 181 minutes). On average, robotic tubal reversal patients returned to work one week sooner than abdominal tubal reversal patients and the robotic tubal reversal surgeries were also more expensive than abdominal tubal reversal surgeries.[5]
An Ohio State University study evaluating robotic tubal reversal vs abdominal tubal reversal discovered similar findings but also evaluated pregnancy outcomes. Robotic tubal reversal surgery, when compared to abdominal tubal reversal surgery, had longer operative times (201 minutes vs 155 minutes), shorter hospital stays (4 hours compared to 34 hours), and quicker return to activities of daily living. Pregnancy outcomes of robotic tubal reversal surgery patients were also compared to pregnancy outcome of abdominal incision tubal reversal patients. Approximately 65% of the robotic tubal reversal surgery patients became pregnant compared with 50% of the abdominal incision patients. Of the pregnancies, 6 abnormal pregnancies were in the robotic tubal reversal patients (4 ectopic and 2 miscarriage) and 2 were in the abdominal incision patients (1 ectopic and 1 miscarriage). Both surgeries were expensive and were found to cost in excess of $92,000. Robotic tubal reversal surgery was slightly more costly than the abdominal incision tubal reversal.[6]
Essure sterilization was a tubal occlusion procedure that was approved by the FDA in 2002. The Essure procedure involves inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. Two small, metallic coils are then inserted into each tubal ostia and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to be blocked with scar tissue. To confirm tubal closure, a hysterosalpingogram should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure can be repeated or another type of tubal occlusion method can be performed. Essure was discontinued in 2018 due to a large number of reported serious adverse events.[7]
Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed by tubouterine implantation. During a tubouterine implantation procedure, the blocked portion of the fallopian tube containing the Essure sterilization device is surgically resected. The remaining portion of each healthy fallopian tube is then reintroduced into the newly created openings. This procedure can restore the natural function of the fallopian tube and allow for natural conception. The first case of successful outpatient tubouterine implantation to reverse Essure sterilization was published in 2012.[8]
Surgeons who published the first case report of successful Essure reversal subsequently published a larger cohort study of 70 patients who underwent outpatient tubouterine implantation to reverse Essure sterilization and 36% of patients reported pregnancy through natural conception.[8]
Dr. Charles Monteith, Medical Director of A Personal Choice Tubal Reversal Center, has collected non-published data on the risks of outpatient Essure reversal surgery.[citation needed] Between 2009 and 2018, Monteith performed 469 outpatient tubouterine implantation procedures to reverse Essure sterilization. He documented intraoperative, postoperative, and pregnancy risks associated with his procedures.
Intraoperative risks observed were failure to complete the planned procedure (either Essure removal and tubal occlusion or Essure removal and bilateral tubouterine implantation) <1%, fracture of Essure devices during removal (approximately 10% risk with manual traction and < 1% with en bloc dissection), transfer to hospital <1%, referral to Emergency room or hospital within 24 hours of surgery <1%, bleeding requiring blood transfusion or hospitalization for operative complication 0%, anesthesia complication 0%, and death 0%.
Postoperative risks observed were major surgical site infection 0%, minor surgical site infection <1%, need for a second operation/procedure within 30 days <1%, and persistent symptoms requiring additional surgery < 10%.
Pregnancy related risks were failure to become pregnant and possible tubal closure (estimated to be <60%) and ectopic pregnancy 5%. All patients were advised to have a planned cesarean delivery before the onset of labor and the risk of uterine rupture was observed to be 4%. The majority of uterine ruptures occurred at 36/37 weeks gestation.
Factors associated with more difficult surgical procedures were patient obesity (BMI ≥ 30), presence of uterine leiomyomas, and uterine adhesive disease primarily from prior cesarean delivery.[9]
Adiana sterilization reversal
Adiana sterilization was approved by the FDA in 2009. Adiana sterilization is a hysteroscopic tubal occlusion procedure, which is very similar to Essure sterilization. The Adiana procedure involves inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. A smaller catheter is inserted into the tubal ostia. The catheter emits radiowaves (microwaves). The radiowaves cause injury to the tubal lining and will result in the tube gradually closing. Prior to removal of the catheter a small silicone stent is left inside the isthmic portion of the tube and this promotes tubal closure by the acceleration of the tubal scarring.
Adiana sterilization is similar to Essure sterilization and the Adiana procedure causes blockage of the proximal isthmic portion. Adiana sterilization can surgical reversed with tubouterine implantation. The first case of successful outpatient tubouterine implantation to reverse Adiana sterilization was published in 2011.[10]
Hologic Corporation discontinued the procedure in March 2012, resolving ongoing litigation with Conceptus concerning patent infringement claims.[11]
Tubal reversal success rates
Tubal reversal success rates vary widely depending upon many factors.[12] These include the women's ages, methods of tubal ligation that they had performed, experience of the surgeon and techniques for repairing the tubes, length of follow-up after reversal surgery among other factors. Overall, for those who are less than 35 years of age at the time of reversal, more than 70% achieve intrauterine pregnancy, with most pregnancies occurring within 18 months after surgery.[12] Overall, for those who are 35 years of age or more, approximately 55% will achieve an intrauterine pregnancy.[12]
Related Research Articles
Ectopic pregnancy is a complication of pregnancy in which the embryo attaches outside the uterus. Signs and symptoms classically include abdominal pain and vaginal bleeding, but fewer than 50 percent of affected women have both of these symptoms. The pain may be described as sharp, dull, or crampy. Pain may also spread to the shoulder if bleeding into the abdomen has occurred. Severe bleeding may result in a fast heart rate, fainting, or shock. With very rare exceptions, the fetus is unable to survive.
Laparoscopy is an operation performed in the abdomen or pelvis using small incisions with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.
Sterilization is any of a number of medical methods of birth control that intentionally leaves a person unable to reproduce. Sterilization methods include both surgical and non-surgical, and exist for both males and females. Sterilization procedures are intended to be permanent; reversal is generally difficult or impossible.
Tubal ligation is a surgical procedure for female sterilization in which the fallopian tubes are permanently blocked, clipped or removed. This prevents the fertilization of eggs by sperm and thus the implantation of a fertilized egg. Tubal ligation is considered a permanent method of sterilization and birth control.
Hysterectomy is the partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. Partial hysterectomies allow for hormone regulation while total hysterectomies do not.
Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.
Falloposcopy is the inspection of the fallopian tubes through a micro- endoscope. The falloposcope is inserted into the tube through its opening in the uterus at the proximal tubal opening via the uterotubal junction; technically it could also be inserted at the time of abdominal surgery or laparoscopy via the distal fimbriated end.
Salpingectomy refers to the surgical removal of a fallopian tube. This may be done to treat an ectopic pregnancy or cancer, to prevent cancer, or as a form of contraception.
Tuboplasty refers to a number of surgical operations that attempt to restore patency and functioning of the fallopian tube(s) so that a pregnancy could be achieved. As tubal infertility is a common cause of infertility, tuboplasties were commonly performed prior to the development of effective in vitro fertilization (IVF) or repair of any type of tube-like structure, including the Eustachian tube in the head and neck.
Robot-assisted surgery or robotic surgery are any types of surgical procedures that are performed using robotic systems. Robotically assisted surgery was developed to try to overcome the limitations of pre-existing minimally-invasive surgical procedures and to enhance the capabilities of surgeons performing open surgery.
Endometrial ablation is a surgical procedure that is used to remove (ablate) or destroy the endometrial lining of the uterus. The goal of the procedure is to decrease the amount of blood loss during menstrual periods. Endometrial ablation is most often employed in people with excessive menstrual bleeding, who do not wish to undergo a hysterectomy, following unsuccessful medical therapy.
Essure was a device for female sterilization. It is a metal coil which when placed into each fallopian tube induces fibrosis and blockage. Essure was designed as an alternative to tubal ligation. However, it was recalled by Bayer in 2018, and the device is no longer sold due to complications secondary to its implantation. The company has reported that several patients implanted with the Essure System for Permanent Birth Control have experienced and/or reported adverse effects, including: perforation of the uterus and/or fallopian tubes, identification of inserts in the abdominal or pelvic cavity, persistent pain, and suspected allergic or hypersensitivity reaction. Although designed to remain in place for a lifetime, it was approved based on short-term safety studies. Of the 745 women with implants in the original premarket studies, 92% were followed up at one year, and 25% for two years, for safety outcomes. A 2009 review concluded that Essure appeared safe and effective based on short-term studies, that it was less invasive and could be cheaper than laparoscopic bilateral tubal ligation. About 750,000 women have received the device worldwide.
A hydrosalpinx is a condition that occurs when a fallopian tube is blocked and fills with serous or clear fluid near the ovary. The blocked tube may become substantially distended giving the tube a characteristic sausage-like or retort-like shape. The condition is often bilateral and the affected tubes may reach several centimeters in diameter. The blocked tubes cause infertility. A fallopian tube filled with blood is a hematosalpinx, and with pus a pyosalpinx.
Fallopian tube obstruction, also known as fallopian tube occlusion is a major cause of female infertility. Blocked fallopian tubes are unable to let the ovum and the sperm converge, thus making fertilization impossible. Fallopian tubes are also known as oviducts, uterine tubes, and salpinges.
The fertiloscope is a type of laparoscope, modified to make it suitable for trans-vaginal application, which is used in the diagnosis and treatment of female infertility.
The fallopian tubes, also known as uterine tubes, oviducts or salpinges, are paired tubes in the human female that stretch from the uterus to the ovaries. The fallopian tubes are part of the female reproductive system. In other mammals they are only called oviducts.
An interstitial pregnancy is a uterine but ectopic pregnancy; the pregnancy is located outside the uterine cavity in that part of the fallopian tube that penetrates the muscular layer of the uterus. The term cornual pregnancy is sometimes used as a synonym, but remains ambiguous as it is also applied to indicate the presence of a pregnancy located within the cavity in one of the two upper "horns" of a bicornuate uterus. Interstitial pregnancies have a higher mortality than ectopics in general.
Ovarian pregnancy refers to an ectopic pregnancy that is located in the ovary. Typically the egg cell is not released or picked up at ovulation, but fertilized within the ovary where the pregnancy implants. Such a pregnancy usually does not proceed past the first four weeks of pregnancy. An untreated ovarian pregnancy causes potentially fatal intra-abdominal bleeding and thus may become a medical emergency.
Irving Operation is a gynaecological operative technique for permanent sterilization in women. It was proposed to reduce the failure rate of Pomeroy procedure for female sterilization. In Irving operation, the proximal part of fallopian tube is buried back into the myometrium, thereby obstructing its lumen.
Chromopertubation is a method for the study of fallopian tube patency for suspected infertility in women caused by fallopian tube obstruction. Occlusion or pathology of the fallopian tubes is the most common cause of suspected infertility. Chromopertubation is sometimes commonly referred to a "laparoscopy and dye" test. It is currently one of the standard procedures in this field. In most cases, chromopertubation is performed to assess and determine the cause of someone's difficulties in getting pregnant.
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