Tubal Reversal Blog ‘fimbriectomy’

Tubal Reversal Procedures

There are 3 types of tubal reversal procedures:

• anastomosis
• implantation
• salpingostomy – (this blog topic)

Salpingostomy Definitions

Salpingostomy is creating an opening in the fallopian tube. It is also called neosalpingostomy, which more clearly indicates the creation of a new opening in the tube. Salpingostomy is the appropriate tubal reversal procedure when the end closest to the ovary is closed and the fallopian tube has not been divided into separate segments. This is what results from a fimbriectomy tubal ligation. It can be seen also when a fallopian tube has become closed as a result of infection (salpingitis).

How I Perform Ampullary Salpingostomy

Salpingostomy involves creating an opening in the end of the fallopian tube with a microsurgical needle electrode. The opening is enlarged and gently folded back so that the internal lining extends over the opened end of the tube. The internal lining is covered with cilia, the hairline projections that beat in coordinated waves. They help capture an egg as it is released from the ovary just as the fimbrial end of the tube does normally. Sutures are placed around the end of the tube that has been folded back. The sutures are hidden underneath the folded-back tubal end. When ampullary salpingostomy is completed, the tubal end looks similar to a normal fallopian tube, provided there is a sufficient ampullary length of tube remaining to fold back.

Types of Salpingostomy

The type of salpingostomy is specified according to the tubal segment that has been opened. This will depend on how much of the fallopian tube was removed during a fimbriectomy. The illustration above shows an ampullary salpingostomy. Salpingostomy at the ampullary, infudibular, or fimbrial tubal segments can result in good success rates. If a large amount of tube has been removed and only the isthmic segment remains, salpingostomy is unlikely to result in pregnancy.

Comment About Salpingostomy

The success of salpingostomy for fimbriectomy tubal reversal depends upon having an adequate length of ampullary segment of the fallopian tube. The length of the remaining ampullary tubal segment can be determined from a hysterosalpingogram (HSG) or from diagnostic laparoscopy. I recommend having an HSG or choosing the screening laparoscopy option when tubal ligation has been performed by fimbriectomy. An HSG can be ordered by the patient’s local doctor and the x-ray films sent to me for examination prior to scheduling tubal reversal surgery. Alternatively, patients can omit having an HSG and schedule their reversal surgery to start with screening laparoscopy. This will show if ampullary salpingostomy will be effective. If so, the tubal reversal procedure will be performed at the same time while the patient is under anesthesia.

Message Board discussion about Microsurgical Salpingostomy

Tubal Ligation by Fimbriectomy

Fimbriectomy is an infrequent type of tubal ligation in the United States. This female sterilization method is performed by removing the fimbrial end of the fallopian tube. At the fimbrial end of the tube, the inner tubal lining faces outward towards the ovary. The tubal lining is rich in cilia that beat in coordinated waves to pull the egg into the tubal opening.

Many doctors think that tubal reversal cannot be successful following a fimbriectomy because of the loss of the egg-capturing fimbria. This is a mistaken notion. Cilia are abundant in the ampullary segment of the fallopian tube. The inner lining of the remaining ampullary tubal segment can be folded outward after opening the tube and can function as a new fimbrial end. The tubal reversal procedure for fimbriectomy reversal is called ampullary salpingostomy.

Fimbriectomy Reversal Pregnancy Rates

Chapel Hill Tubal Reversal Center publishes statistics updated annually regarding pregnancy rates and pregnancy outcomes for all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal ligation procedures by fimbriectomy are from our Tubal Reversal Pregnancy Study Report 2007.

The overall pregnancy rate after fimbriectomy tubal reversal is 56% for patients at Chapel Hill Tubal Reversal Center. The following table shows the numbers and pregnancy rates according to womens’ ages at the time of their tubal reversal procedure.

Pregnancy Rates After Fimbriectomy Reversal

Recommendations for Fimbriectomy Reversal

The success of fimbriectomy reversal depends upon having an adequate length of ampullary segment of the fallopian tube. The length of the remaining ampullary tubal segment can be determined from a hysterosalpingogram (HSG) or from diagnostic laparoscopy.

I recommend having an HSG or choosing the screening laparoscopy option when tubal ligation has been performed by fimbriectomy. An HSG can be ordered by the patient’s local doctor and the x-ray films sent to me for examination prior to scheduling tubal reversal surgery. Alternatively, patients can omit having an HSG and schedule their reversal surgery to start with screening laparoscopy. This will show if ampullary salpingostomy will be effective. If so, the tubal reversal procedure will be performed at the same time while the patient is under anesthesia.

Almost every article one reads about tubal ligation stresses that it is permanent. Most doctors and the lay public believe this to be true. In my experience, however, tubal ligation is reversible in over 95% cases!

Doctors stress that tubal ligation is a permanent method birth control because it cannot be discontinued easily such as stopping the use of birth control pills or the patch, removing an IUD, or avoiding the use of barriers contraceptives (condom or diaphragm). In the past, reversing a tubal ligation procedure involved complicated surgery with its attendant high cost (up to $35,000). The outpatient tubal ligation procedure that I have developed is uncomplicated surgery and avoids the expense of hospital charges. This has reduced the cost of tubal reversal surgery to under $6000. This is less than the cost of a single treatment cycle with in vitro fertilization (averaging $10,000 – $12,000). My effort over the past 3 decades has been to make tubal reversal surgery easy to undergo and affordable for couples.

There are some methods of female sterilization that are not reversible. These include complete removal of the fallopian tubes (total salpingectomy) and extremely destructive methods of partial salpingectomy that do not leave two segments to repair. An example of the latter is when only a short portion of the tube is attached to the uterus and the remaining segment contains only fimbrial tissue with no tubal muscle or opening. In this case, the fimbrial tissue alone cannot be rejoined successfully to the uterine segment of tube. Fortunately, this is an unusual occurrence. In cases where there is a sufficient length of tube attached to the uterus, it can be opened and be able function normally even without the fimbrial end. This is called ampullary salpingostomy. This technique is useful in reversing a fimbriectomy (removal of the fimbrial or ovarian end of the fallopian tube).

Reviewing the operative report from a tubal ligation procedure usually will indicate how destructive the procedure was. When there is a question about this, diagnostic laparoscopy can be performed to examine what remains of the fallopian tubes. If there are sufficient segments to repair, tubal reversal can be done right then while the patient is under anesthesia.

The best method of tubal ligation to reverse is the clip procedure. The Hulka Clip was developed in the 1970s by Dr. Jaroslav Hulka, a professor of obstetrics and gynecology at the University of North Carolina at Chapel Hill. (Dr. Hulka was one of my most influential teachers during my residency in ob-gyn at UNC.) The tubal ring also is an excellent method for reversing. The clip and ring procedures tend to damage the least amount of the fallopian tube and leave behind long segments to repair.

The most common tubal ligation procedures involves tying and cutting the tubes (ligation/resection) or burning the tubes (coagulation). Experience shows that 98% of these procedures are reversible.

Summary: Tubal ligation is not really permanent in the sense that it can be reversed in almost all cases. This is fortunate for those women who want another chance to have a baby after having their tubes tied. Tubal reversal is more successful, less complicated, and less expensive than the alternative treatment of in vitro fertilization.