Tubal Reversal Blog ‘research’ Category

Salpingitis Isthmica Nodosa

Salpingitis isthmica nodosa is a nodular swelling of the isthmic segment of the fallopian tube. This fallopian tube abnormality is sometimes encountered at the time of tubal reversal surgery. It often involves the interstitial portion of tube that is within the uterine muscle. The nodule is due to thickening of the muscular wall of the tube around ingrowths or projections of the inner mucus membrane tubal layer into the muscle.

History of Salpingitis Isthmica Nodosa: Scholarly Publications

This tubal abnormality was first described and named by Chiari in 1887 .⁽¹⁾ The name he gave it reflected his belief this was an inflammatory condition. (Salpingitis means inflammation of the fallopian tube.) His contemporary, Kossman, also thought this was an inflammatory condition.⁽²⁾ An alternate theory of causation was suggested by Recklinghausen in 1896 who believed it to be a congenital abnormality.⁽³⁾ A third possibility, suggested by Benjamin and Beaver in 1951, is that SIN is an acquired, noninflammatory condition.⁽⁴⁾ They believed that the lesion begins as an overgrowth of the inner tubal lining that penetrates into the tubal muscular wall. Then cysts form and the tubal muscular wall becomes enlarged and fibrotic. This has also been termed endosalpingosis, a condition closely related to uterine adenomyosis (a form of endometriosis in which the uterine endometrium grows into the uterine muscle).

HSG Diagnostic Findings

Salpingitis isthmica nodosa can be diagnosed radiographically. A hysterosalpingogram or HSG shows multiple small diverticuli or outpouchings of of x-ray dye protruding from the tubal lumen into the wall of the isthmic portion of the fallopian tubes. Because of its appearance at HSG, radiologists call it tubal diverticulosis.⁽⁵⁾

Clinical Implications

Salpingitis isthmica nodosa is associated with increased rates of infertility by interfering with upward sperm migration and ectopic pregnancy by trapping the fertilized egg within the tube.

Treatment During Tubal Reversal

Salpingitis isthmica nodosa may be encountered at the time of tubal reversal surgery. Because of the dense abnormality of the fallopian tube at its connection with the uterus, tubotubal anastomosis is not possible. In this situation, tubouterine anastomosis or tubouterine implantation can be performed.

Tubal Reversal Scholarly Publications

Early Experimental Studies in Animals

In 1969, David, Brackett and Garcia ⁽¹⁾ reported using microsurgical techniques for uterotubal anastomosis after removing the uterotubal junction from one side in 25 rabbits. Among 11 (44%) of the animals that became pregnant, fewer implantations occurred on the operated side than on the unoperated side. This showed that the uterotubal junction has a role, but is not absolutely required, in transferring embryos from the fallopian tube into the uterus for implantation.

In 1974, Paterson and Wood ⁽²⁾ divided the isthmic segment of one fallopian tube and then performed tubal anastomosis in 10 rabbits. They removed the fallopian tube and ovary on the other side so that any pregnancies that followed could be attributed to the repaired fallopian tube. The pregnancy rate was 60%. These investigators suggested that tubal anastomosis could be applied successfully to humans for reversal of tubal sterilization.

Hulka and Ulberg ⁽³⁾ in 1975 were the first to perform a successful reversal of tubal sterilization under experimental conditions. Six weeks after applying Hulka clips to the isthmic portion of fallopian tubes in 8 pigs, they removed the clipped portion of tubes and performed tubal anastomosis using an absorbable, multifilament suture (6-0 Dexon). Six (75%) of the animals subsequently became pregnant.

In 1975 Winston ⁽⁴⁾ reported an experiment in rabbits in which the experimental variables were different suture materials and duration of tubal splinting. In one group of 25 rabbits, he removed a portion of the tubal isthmus or ampulla and then performed tubotubal anastomosis with a nonabsorbable, nonreactive, monofilament suture (10-0 nylon). Using microsurgical technique, Winston took special care to include only the 2 outer layers (muscularis and serosa) of the fallopian tube in the suture line, avoiding the inner tubal layer (endothelium). He stabilized the anastomotic sites with polyethylene splints that were removed before closure of the abdominal cavity. Twenty-three (92%) of the animals became pregnant. This was the highest pregnancy rate reported so far after tubal anastomosis in animal studies. When either 8-0 catgut was used as the suture material or the tubal splint was left in place for 1 week after surgery, the pregnancy rate dropped in half.

Winston’s results were subsequently corroborated using microsurgical tubal anastomosis with 11-0 nylon, intraoperative splinting, and avoiding mucosal trauma from suture in the reconstruction of rabbit oviducts six weeks after application of Falope rings. Eighteen (82%) of 22 rabbits became pregnant after two matings.

Comment

Experimental studies in animals demonstrated excellent pregnancy rates following reconstruction of the fallopian tube by tubal anastomosis. They provided the basis for tubal reversal surgery as a clinical treatment. The best results came using microsurgical techniques with non-reactive, monofilament suture material, intraoperative tubal splints, and avoiding the introduction of suture in the inner layer of the tube.

Dr. Berger uses these surgical techniques in his tubal reversal procedures. For a more complete description of the early history of tubal reversal surgery, read Dr. Berger’s book chapter, Reversal of Female Sterilization: An Evaluation of Results ⁽⁵⁾.

References

1. David A, Brackett BG, Garcia CR: Effects of microsurgical removal of the rabbit uterotubal junction. Fertil Steril 20:250, 1969
2. Hulka JF, Ulberg LC: Reversibility of clip sterilization. Fertil Steril 26:1132, 1975
3. Paterson P, Wood C: The use of microsurgery in the reanastomosis of the rabbit fallopian tube. Fertil Steril 25:757, 1974
4. Winston RML: Microsurgical reanastomosis of the rabbit oviduct and its functional and pathological sequelae. Br I Obstet Gynaecol 82 :513, 1975
5. Berger GS: Reversal of female sterilization: An evaluation of results. In JM Phillips, editor, Microsurgery in Gynecology, Chapter 33. American Association of Gynecologic Laparoscopists, Downey, California, 238-243, 1977.

Gary S Berger MD, Medical Director of Chapel Hill Tubal Reversal Center, is well known for his contributions to clinical medicine as a reproductive surgeon. Patients sometimes ask about Dr. Berger’s education, training, academic credentials, scholarly research and publications.

This is a resume of Dr. Berger’s academic credentials:

ACADEMIC DEGREES

1965 A.B. with Honors
Harvard College
Boston, Massachusetts

1969 M.D.
University of Rochester
Rochester, New York

1976 M.S.P.H.
University of North Carolina
School of Public Health
Chapel Hill, North Carolina

POSTGRADUATE EDUCATION

1969 – 1970 Intern
Department of Internal Medicine
Duke University Hospital
Durham, North Carolina

1970 – 1971 Assistant Resident
Department of Gynecology and Obstetrics
Johns Hopkins Hospital
Baltimore, Maryland

1971 – 1973 Epidemic Intelligence Service Officer
Family Planning Evaluation Program
Bureau of Epidemiology
Centers for Disease Control
U.S. Public Health Service
Atlanta, Georgia

1973 – 1976 Resident
Department of Obstetrics and Gynecology
University of North Carolina
Chapel Hill, North Carolina

ACADEMIC APPOINTMENTS

1976 – 1979 Assistant Professor
Department of Obstetrics and Gynecology
University of North Carolina at Chapel Hill
Chapel Hill, NC

1980 – 2003 Adjunct Associate Professor
Department of Maternal and Child Health
School of Public Health
University of North Carolina at Chapel Hill
Chapel Hill, NC

1992 – 2003 Clinical Associate Professor
Department of Obstetrics and Gynecology
University of North Carolina
Chapel Hill, NC

SCHOLARLY PUBLICATIONS

Dr. Berger has published more than 160 peer-reviewed scientific articles in medical journals. He has also authored or edited these medical books:

D.A. Edelman, G.S. Berger and L.G. Keith. Intrauterine Devices and Their Complications. G.K. Hall, 1979.

L.G. Keith, M. Labbok, J. Petty, and G.S. Berger. Postpartum and Postabortal Contraception. Synapse Publications, 1979.

L.G. Keith, D.R. Kent, G.S. Berger, and J.R. Brittain, editors. The Safety of Feliility Control. Springer Publishing Company, 1980.

M. Jackson, G.S. Berger and L.G. Keith. Vaginal Contraception. G.K. Hall, 1980.

L.G. Keith, G.S. Berger and D.A. Edleman, editors. Infections in Reproductive Health: Common Infections. Vol. I, MTP Press Ltd., 1985.

L.G. Keith, G.S. Berger and D.A. Edelman, editors. Infections in Reproductive Health: Uncommon Infections and Special Topics. Vol. II, MTP Press, Ltd., 1986.

M. Bygdeman, G.S. Berger, L.G. Keith, editors. Prostaglandins and Their Inhibitors in Clinical Obstetrics and Gynecology. MTP Press, Ltd., 1986.

G.S. Berger, M. Goldstein and M. Fuerst. The Couple’s Guide to Fertility. Doubleday and Company, 1985.

G.S. Berger, L.V. Westrom, editors. Pelvic Inflammatory Disease. Raven Press, 1992.

C. Nezhat, G.S. Berger, V.C. Buttram, and F. Nezhat, editors. Endometriosis: Advanced Management and Surgical Techniques. Springer-Verlag, 1995.

G.S. Berger, M. Goldstein and M. Fuerst. The Couple’s Guide to Fertility, revised edition. Doubleday and Company, 1995.

G.S. Berger, M. Goldstein and M. Fuerst. The Couple’s Guide to Fertility: With the Newest Scientific Techniques to Help You Have a Baby. Broadway Books, 2001.

Dr. Berger – Clinician and Scholar

Dr. Berger’s contributions to reproductive medicine and surgery show that a clinician whose primary responsibility is in the care of individual patients can also be a scholar contributing to academic research. This is the basis of Dr. Berger’s ongoing Tubal Reversal Pregnancy Study that documents and analyzes the clinical outcomes of his patients following tubal reversal surgery.

Chapel Hill Tubal Reversal Center Mission

Chapel Hill Tubal Reversal Center is the only medical facility specifically for tubal ligation reversal surgery. We provide the most detailed information about tubal reversal available from any doctor, hospital, or medical institution. This blog post describes how we are able to do this.

Electronic Patient Database

Keeping track of patients following surgery makes sense from a clinical point of view. Continuing follow-up after surgery helps ensure the best patient care. It also allows us to evaluate the success of tubal reversal surgery and the care we provide. Setting up and maintaining a system for ongoing patient follow-up is not usually found in a private medical practice. It is costly, time-consuming, and requires staff knowledgeable in database management. Despite the cost and time requirements, I have made it a priority because of my commitment to giving patients all of the information they should have to make informed decisions about tubal reversal surgery.

At Chapel Hill Tubal Reversal Center, we have a computer system where every nurse enters patient information before, during, and after tubal reversal procedures. All 11 of our nurses contact patients, record data, and make daily entries into computerized records. With this follow-up information, I can analyze and report accurate statistical data about the long-term outcomes of the tubal reversal procedures I have performed.

Information Sources

The patient follow-up system consists of information collected in many different ways and includes a minimum of 6 calls or e-mails to every patient in the first year following surgery:

1. Post-operative nurse visit the morning after surgery;
2. Telephone follow-up on the second postoperative day;
3. Telephone follow-up on the third postoperative day;
4. E-mail questionnaire at two weeks;
5. Telephone contact at 6 months;
6. Telephone contact at 12 months.

Other information is collected and recorded any time we communicate with patients post-operatively. These contacts are usually initiated by patients to report pregnancies and the outcomes of pregnancies. When patients report new pregnancies, we request that they complete a Pregnancy Report Form. Each week, we list the new pregnancy results in the Weekly Pregnancy Report Forum of the Tubal Reversal Message Board and also give more details in the Weekly Pregnancy Announcements.

Summary

After reading our information and statistics and comparing it to what might be available from other doctors, we believe patients will recognize that Chapel Hill Tubal Reversal Center is the only facility where accuracy of information is considered a priority and sharing it with prospective patients is considered a necessity. Providing facts, rather than offering misleading or speculative statements about tubal reversal success, is one mission of our practice. We believe this is the right thing to do.

What is Essure?

Essure is a permanent birth control device that has recently become available as an alternative to traditional tubal ligation methods. The spring-like device is inserted through the uterine cavity into the tubal openings using a hysteroscope. This can be done as an in-office procedure. The device expands to fill the tubal opening and then becomes scarred into place, forming a barrier so that sperm cannot reach the egg. Because of the scar formation, it cannot be pulled out of the tube. It is advertised by the manufacturer as a permanent method of birth control. In this respect, it is similar to other tubal ligation methods that are considered by most doctors to be permanent.

Here is a link to an online video animation of the placement of the Essure device into the fallopian tubes.

Is Tubal Reversal Possible For The Essure Device?

I perform 4 tubal reversal procedures each day at Chapel Hill Tubal Reversal Center. The women who come here have all varieties of tubal ligation methods. Today, one of the patients had the Essure sterilization method. When she chose this form of tubal sterilization, she was unaware that she would become remarried and want to be able to try to have a child with her new husband.

Although I could not find any previous references regarding attempts to reverse the Essure procedure, I agreed to attempt to perform a reversal for her. The way I did this was to cut the device out of the uterine muscle and then implant the remaining fallopian tube into the uterine cavity through a new opening in the uterus. This procedure is called tubouterine implantation.

The reason I removed the device was that part of the metal spring projects into the uterine cavity. If a pregnancy were to occur with the device in place, this could be harmful to the pregnancy. To my knowledge, this is the first time that the Essure sterilization procedure has been reversed.

Answers To Common Questions About Essure Reversal

We have provided answers to common questions about Essure reversal in the following blog article,  Essure Reversal: What You Need To Know .

Pomeroy Technique of Tubal Ligation and Resection

The most common type of tubal ligation is the Pomeroy procedure, named after Dr. Ralph Pomeroy who described it in 1930. The Pomeroy method involves picking up a segment of the fallopian tube to create a knuckle, placing a tie or ligature with absorbable suture around its base, and then cutting off the knuckle of tube above the tie. As the suture dissolves, the 2 remaining tubal segments separate from each other.

“Modified” Pomeroy Techniques

Interestingly, Dr. Pomeroy did not publish his technique in the medical literature but simply demonstrated it to other doctors. Some of them subsequently published the technique, but with modifications.

Currently, many doctors use the term modified Pomeroy procedure when they describe the tubal ligation they have performed in a patient’s operative report. Each doctor seems to have his or her own way of operating and there are many variations from the original method. Some doctors use absorbable suture, while others use permanent sutures that do not dissolve. Some doctors place more than one tie around the tube and many doctors also burn or cauterize the tubal ends.

A tubal ligation operative report is useful as a guide but does not predict exactly what the remaining tubal segments will be at the time of a reversal procedure. Fortunately, Pomeroy tubal ligation and its modifications are usually excellent in terms of reversibility.

Pomeroy Tubal Ligation Reversal Success

At Chapel Hill Tubal Reversal Center, we keep a record of all patients’ tubal reversal operations, including the tubal ligation method, the remaining tubal segment lengths, and other important findings at the time of surgery. Since we maintain long term follow-up with our patients, we are able to provide accurate statistics about pregnancies and their outcomes after tubal reversal surgery. Here are some of the pregnancy statistics for women who have had a Pomeroy type of tubal ligation.

Pregnancy Rates of Our Tubal Reversal Patients

The overall pregnancy rate after Pomeroy tubal ligation reversal is 70% for patients at Chapel Hill Tubal Reversal Center. The table below shows pregnancy rates according to women’s ages at the time of tubal reversal. The first column shows ages by 5 year groupings. The second column shows the number of women in each age group who had a tubal reversal. The third and fourth columns show the number and the percentage of women who became pregnant after their reversal procedure. The data shown in this table come from our Tubal Reversal Pregnancy Study Report 2007.

Here is how the pregnancy rate is calculated: The number of pregnant women (column 3) divided by all women in that age category who had reversal surgery (column 2) times 100 equals the percentage of women who became pregnant (column 4). A doctor has to know all of this information in order to be able to state what the success rate is for his patients.

Pregnancy Rate By Age After Pomeroy Tubal Reversal

Good News About Pomeroy Reversal

The good news is that for women under age 40, two-thirds to four-fifths will become pregnant following a tubal reversal procedure. Even for women age 40 and over, approximately 4 out of 10 will conceive another pregnancy. From the follow-up data that we have for our tubal reversal patients, there is good reason for optimism when reversing a Pomeroy tubal ligation.

The circumstances that lead people to have a tubal reversal procedure are unique to each person. Understanding them is helpful to me as a tubal reversal specialist providing their care during and after tubal reversal surgery.

Preoperative Consultation

When meeting new patients, I begin the preoperative consultation by asking about the circumstances that have them brought to me. After greeting patients and having them get settled comfortably in my office, I ask: What made you decide to have a tubal reversal at this time? Each person or couple responds in their own way to this nondirective question, often touching on their personal, social, and medical history that have brought them to this point in their lives. Their responses provide the context for the discussion that follows about their tubal reversal procedure.

Reasons for Tubal Reversal

The reasons given for having a tubal reversal vary. The most common one is that the patient is in, or about to enter, a new marriage. Often, the man has no biological children. Even when both partners have children from previous marriages, they want to establish a family of their own. Less commonly, couples who already have children together want to expand their family. For these couples, their past choice to have a tubal ligation is no longer the right decision for them. Sometimes they describe religious considerations, a change in financial stability, or tragically, the death of a child.

Tubal Ligation Regret

Many women have told me that they had a tubal ligation as a way out of a bad situation. Some did not want to have any more children while in a failing or abusive marriage. Others felt pressured into having their tubes tied by a parent, other family members, spouse, or even their doctor. Women who had their tubes tied while undergoing a C-section often report they made a hasty decision while in labor and almost immediately felt that it was a mistake.

Post Tubal Ligation Syndrome

An increasing number of women describe a variety of symptoms that started when they had their tubes tied. Most often these include heavy or painful periods, headaches, irritability, or other emotional reactions that were not present before their tubal sterilization. Many of these patients have been treated by their doctors with hormones, anti-depressants, or other medications to no avail and usually have been told that Post Tubal Ligation Syndrome does not exist. But they are convinced from their own histories that it does. A study that we are currently conducting finds that over 90% of these women report improvement or complete relief of their symptoms after tubal reversal surgery. Clearly, more research about this controversial subject is warranted.

Informed Consent and Patient Follow-up

Whatever the reasons for having a tubal reversal, it is important for patients to be fully informed about the potential benefits and risks of the operation. Equally important is the long term follow-up that we maintain with patients after surgery. This has enabled us to document and report the outcomes of tubal reversal surgery to a much greater extent than has ever been done before.

Chapel Hill Tubal Reversal Center

Chapel Hill Tubal Reversal Center is the only medical center exclusively for tubal ligation reversal. Patients travel from all over to have their tubal reversal procedures performed here. After surgery, each patient puts a pin in the map indicating where she is from. The map below shows that people come from all over the country. In fact, patients come here from all over the world.

Why Patients Come Here

Why are people willing to travel so far for a surgical procedure? They tell me it is to get the best outcome that is possible. Most patients have found out about us while doing research about tubal reversal surgery and doctors on the internet. Many have seen “The Operation“ on TV or the free video or dvd that we send out on request. This video gives a real couple’s perspective of the outpatient procedure and how well it works. When it comes to having a very much wanted baby, most people are willing to travel to get the best outcome.

What They Say About Us

To have an idea of what it is like to be one of our patients, read what previous patients have said about their experiences here. There are thousands of comments on various website pages such as About Us and Pregnancy Testimonials. Or visit an independent website such as RateMDs.com. Here are a few of the comments patients have made on this doctors rating site:

“Dr. Berger and his staff were awesome!!!! They were extremely kind and patient, very approachable, and every detail of my surgery and recovery were explained. I only needed pain medication the first night following my surgery and I was able to resume my normal activities the next day. I would highly recommend Dr. Berger to everyone considering tubal reversal surgery. God has granted him the power to make miracles happen.” Shelia TR 06/08/07

“The care I received from Dr. Berger was phenomenal. It was the most professional and compassionate medical experience I have ever had. The follow up care has been just as impressive even now, over a year and a half later. Dr. Berger is the best choice a couple could possibly make.” Julia and Kevin Disorda – Vermont

“Dr. Berger and his staff are just amazing, not only as people but at the work they do. I traveled from California to see Dr. Berger and could not be happier with my decision. I was so pleased with how fast my recovery was and that I had no pain after the surgery. Dr. Berger and staff are there for you whenever you need them, and will make you feel as if you are family.” Sharon Lincoln – California

The fallopian tube is an amazing and versatile reproductive organ. Its functions include capturing an egg from the ovary at the time of ovulation; nourishing the fertilized egg or zygote during its early cell divisions; and delivering the blastocyst into the uterine cavity when it is time for implantation. The different parts of the fallopian tube correspond to these various functions.

Tubal Anatomy

The end of the tube furthest from the uterus is the fimbria. The fimbrial segment is lush with cilia that beat vigorously and sweep the egg into the tube where it is fertilized. The egg is quickly moved by the bell-shaped infundibular segment into the ampullary region of the tube. Over the next several days, the combination of muscular contractions and ciliary movement move the egg toward the uterus. The ampulla provides nourishing fluid that allows repeated cell divisions. When the dividing egg (zygote) reaches the stage where the outer membrane dissolves (blastocyst), it is time to be delivered into the uterine cavity. This is the function of the muscular isthmic segment of tube closest to the uterus.

Does Anatomy Predict Function After Tubal Reversal?

Given the complexity of the functions of the fallopian tube, one might wonder if any portion is essential for pregnancy to occur. Years ago, based on the information available in medical texts, I assumed that there would be essential parts or a minimum length of tube needed to result in a normal pregnancy. However, there was little information available to answer this question. Therefore, I began recording the portions of tube removed, tubal segment lengths remaining, and other details about each patient’s reversal operation in an electronic database. Since the staff members at Chapel Hill Tubal Reversal Center follow-up with patients regarding pregnancy after tubal reversal, it has become possible to study the interaction of tubal anatomy and the tube’s ability to function normally.

A Surprising Discovery

Over the 30 years that I have been performing tubal reversal procedures, I have seen every variation of tubal ligation imaginable regarding the sections of tubes removed and lengths of tube remaining to repair. It was surprising to learn that no specific part of the fallopian tube is absolutely required for pregnancy to occur. Somehow, the fallopian is able to compensate for the loss of specific parts and still function normally! Based on this knowledge, I am optimistic in being able to repair any kind of tubal sterilization procedure with the expectation that it will allow the possibility of having more children.

People often wonder “If I do get the tubal reversal procedure done, what are the chances I’ll conceive?”

Dr. Berger is the only doctor who tracks his specific success rate - others doctors will just quote what has been published elsewhere or what they think the success rate should be. Dr. Berger has taken the time and the expense to meticulously keep track of his patients’ pregnancies needed to determine the success rate of the tubal reversal procedures he has performed.

Success Rates

One way to estimate your probability of success after a tubal reversal procedure is from the operative report from your tubal ligation. This can be obtained from the doctor who performed the surgery or from the medical records department of the hospital where your procedure was performed.

If you would like to forward this information to us, Dr. Berger will review the operative report at no charge and we can contact you regarding possible outcomes for you following reversal surgery. You may fax the records to us at 870-934-9211. Please include all contact information (phone and e-mail) when faxing your records.

If you have questions about your chances to get pregnant after a tubal reversal, please feel free to contact me.

Julia Smith, RN
Nurse Administrator
Chapel Hill Tubal Reversal Center
Phone: (919) 656-8204
Fax: 870-934-9211