Tubal Reversal Blog ‘anastomosis’

Tubal blockage or tubal occlusion (the medical term) is the reason that tubal ligation prevents pregnancy. The blockage of the fallopian tube prevents joining of the sperm and egg and prevents eggs from being able to reach the uterine cavity. In the case of tubal sterilization, tubal blockage is intentional. Tubal blockage may also occur due to disease conditions and result in involuntary infertility. Tubal blockage, whether intentional or from disease,  can be corrected with reconstructive tubal surgery.

Facts about Tubal Blockage

Tubal blockage affects millions of women in the US and hundreds of millions worldwide. More than 10 million women in the US, and more than 100 million worldwide, have had a tubal sterilization. There are approximately 6 million infertile couples in the US. It is estimated that 10-20% (600,000 to 1.2 million) cases of infertility may be due to tubal disease. In the majority of cases, tubal occlusion due to disease is caused by pelvic inflammatory disease (PID), an infection of the fallopian tubes (salpingitis) and sometimes the ovaries and pelvic cavity. PID is  “silent”, unrecognized, or misdiagnosed in many and perhaps in the majority of cases.

Read the rest of this article and comment on it. »

We periodically write case reports on patients who undergo tubal ligation reversal at Chapel Hill Tubal Reversal Center. The patient we will profile today had a ligation reversal procedure at our center last month.

She and her husband traveled to Chapel Hill from West Virginia. She is 34 years old and previously was an in-vitro fertilization (IVF) nurse. She is the mother of two children (ages 5 and 2). Her husband works as an engineer and is the father of both of their children. She had a tubal ligation after her second child because of two difficult, high-risk pregnancies.

Her first pregnancy was a vaginal birth complicated by heavy post-partum bleeding. Her heavy bleeding required a dilation and curettage (D and C) and emergency abdominal surgery to control the blood loss. She was diagnosed as having a placenta accreta. This is a condition where the placenta has invaded into the uterus too deeply and does not separate normally from the uterus at the time of delivery. She recovered from this surgery and eventually had a second pregnancy. This child was delivered by C-section and she had a Pomeroy tubal ligation done during the C-section. The operative report described tying and cutting the tubes as well as burning the ends. The pathology report described 1.5 cm tubal segments as being removed.

She explained to us, “My decision to have a tubal ligation was not done prayerfully but was more of a medically made decision.” She and her husband now desire more children in their life, and they traveled to Chapel Hill Tubal Reversal Center to have her tubal ligation reversed.

We were concerned that her doctor described in the operative report the tubal cauterization (burning) after tying and cutting the tubes. Since the mention of the cauterization was vague (we had no idea if a small segment was burned or the entire tube was burned) we discussed starting with a screening laparoscopy. Our patient was able to talk to her doctor who performed the tubal ligation. The doctor assured her only the ends of the tubes were burned. Since this can be a common practice and seemed minimal, the decision was made to proceed with ligation reversal without starting with a screening laparoscopy.

During her operation we found the right fallopian tube was abnormal. The right tube was long and healthy appearing, but there was no fimbriated end of the tube. This area is one of the most critical areas of the tube. The fimbriated ends act like millions of small fingers, which pick up the egg and direct the egg down the tube. The repair of this tube would require a more difficult microsurgical salpingostomy and creation of a ‘neo-fimbriated’ end of tube.

A microsurgical salpingosotomy was performed on her right tube. The left side was more normal- we had two tubal segments that we repaired with the usual anastomosis procedure. The entire operation was about one hour and fifteen minutes.

The story of this patient illustrates several important concepts:

1. She was a knowledgeable medical professional. She understood what it meant to have a tubal ligation. Many patients of all walks of life will have changes of heart as their lives change. Even medical professionals will make health care decisions for themselves, which later turn out to not be right for them. None of us can predict the future.

2. She was an IVF nurse and was aware of the pros and cons of tubal ligation reversal vs IVF. She and her husband decided ligation reversal was a more appropriate path for them.

3. Operative and pathology reports provide helpful information in planning for tubal repair, but they can sometimes be misleading.

4. The right tube was very difficult to repair. Often we will question ourselves as to whether a difficult tube should be repaired or should we just focus on the ‘better’ tube. We can never predict with 100% certain what will or will not work to help get a patient pregnant, so we like to give all patients the benefit of the doubt and try at all costs to open all the tubes we operate on.

We wish her and her husband a successful outcome of her tubal reversal operation and hope their prayerful decision will be soon rewarded.

Submitted by Dr. Charles Monteith

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.

Tubal Reversal Procedures

There are 3 types of tubal reversal procedures:

• anastomosis – (today’s blog topic)
• implantation
• salpingostomy

Anastomosis of Fallopian Tubes

Anastomosis connects two body parts. Tubotubal anastomosis is connecting two segments of the fallopian tube. Tubotubal anastomosis is correct medical terminology, but it is also called tubal anastomosis for short. Bilateral tubal anastomosis means that both tubes are repaired by the anastomosis technique. The anastomosis sites can be specified for each fallopian tube. They may be different for the two sides. For example, a patient may have a right isthmic-ampullary tubotubal anastomosis and a left ampullary-ampullary tubal anastomosis. Sometimes, only one fallopian tube is repairable with the anastomosis technique. This is called unilateral tubotubal anastomosis.

Bilateral Tubal Anastomosis

Most tubal ligation operations separate the fallopian tube into two segments. Bilateral tubotubal anastomosis, therefore, is the most common tubal reversal procedure. Bilateral tubal anastomosis accounts for 90% of the tubal reversal procedures at Chapel Hill Tubal Reversal Center.

How I Perform Tubal Anastomosis

After opening the blocked ends of the two tubal segments, I pass a flexible stent or thread through the tubal lumen or opening of the two segments until it reaches the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end and that the tubal segments align properly. A suture placed in the connective tissue, just beneath the fallopian tube segments, draws the tubal segments together.

The muscular and outer layers of the tubal segments are connected with microsurgical sutures. Care is taken to avoid suturing the inner layer of the fallopian tube. Suture material is a foreign body. Stitches placed in the inner tubal lining can cause scarring inside the tubal lumen. When the two tubal segments are joined together, the stent is withdrawn from the fimbrial end of the tube.

Watch The Operation

The images above illustrate the principles of tubotubal anastomosis. For more details, you can watch the operation as it is being performed. A short video clip online gives an overview. If you want to watch the entire tubal anastomosis procedure, you can order a videotape or dvd of Tubal Ligation Reversal by Dr. Berger as shown on TV by the Discovery and Learning Channels. Watching the full length video will help you better understand how I perform tubotubal anastomosis as outpatient tubal reversal surgery.