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Pelvic Endometriosis in Uncommon Locations
Diagnosed During Tubal Reversal Surgery

These are intra-operative photos I have collected during a 12-month interval of performing out-patient tubal ligation reversal surgery.

In all cases, no patient gave a history of endometriosis before tubal ligation and endometriosis was not diagnosed during the patient’s tubal ligation procedure. In all cases, the diagnosis of endometriosis was made by visual identification of typical endometriosis lesions and the visualized endometriosis was usually the site of tubal ligation. We do not routinely send tissue to pathology for confirmation because of cost concerns in a self-pay environment.

Deep nodular pigmented endometriosis, fibrosis, and adhesion formation

endometriosis and scar tissue from tubal ligation

Deep nodular endometriosis after tubal coagulation

This patient had previously undergone tubal coagulation (tubal burning) as the method of tubal occlusion. Deep nodular, pigmented endometriosis was discovered underneath the proximal segment of fallopian tube. The white-ish appearance of the muscularis is suggestive of fibrosis and is commonly observed after tubal coagulation. The green arrow demonstrates a normal healthy appearing distal fallopian tube segment. The red arrow demonstrates an intestinal adhesive band to the mesosalpinx near the tubal ligation site.

 

 

Superficial pigmented endometriosis of Broad ligament

endometriosis-around-tube-after-tubes-tied

Superficial pigmented endometriosis of Broad ligament

This patient had previously undergone a ligation and resection (cut and tie) method of tubal ligation.

During reversal surgery, we discovered superficial pigmented endometriosis on the serosal surface of the Broad ligament underneath the proximal tube.

The yellow arrow demonstrates the proximal tube and the black arrow demonstrates superficial endometriosis.

 

 

Superficial pigmented and non pigmented endometriosis

Difficult to see endometriosis after tubal ligation

Both pigmented and non pigmented endometriosis of Broad ligament.

This patient had previously undergone a ligation and resection (cut and tie) type of tubal ligation. During reversal surgery, we discovered both superficial pigmented endometriosis and non-pigmented endometriosis on the serosal surface of the broad ligament underneath the distal segment of fallopian tube. The black arrow demonstrates superficial pigmented endometriosis. The yellow arrow demonstrates a superficial non-pigmented blister suggestive of non-pigmented endometriosis. This type of endometriosis can commonly be missed due to the lack of pigmentation, which assists in the visual identification of endometriosis.

 

 

Deep nodular endometriosis and fibrosis

Endometriosis-inside-tube-after-a-tubal-ligation-procedure

Deep pigmented endometriosis with surrounding fibrosis.

This photo demonstrates deep nodular, pigmented endometriosis involving the proximal segment of the fallopian tube. This endometriosis was deep and hard to visualize. The surrounding white fibrosis of the tubal muscularis is only visible when pressure is applied directly to the tubal segment. This causes a blanching effect presumptively due to compromised circulation as a result of the tubal ligation procedure.

This deep endometriosis and tubular fibrosis could easily be missed during a simple visual inspection.

 

 

Pigmented endometriosis associated with tubal clip ligation

endometriosis caused by tubal clip

Pigmented endometriosis with Filshie clip.

Although we commonly observe endometriosis with tubal coagulation and ligation and resection methods of tubal sterilization, we also have observed tubal endometriosis associated with tubal clips and tubal ring methods of tubal ligation.

This photo demonstrates a Filshie clip deeply embedded in the Broad ligament with surrounding fibrosis. The green arrow demonstrates the very end of the tubal clip with the dark pigment associated with endometriosis. Upon removal of the clip ‘dark chocolate fluid’ consistent with endometriosis was inside the tubal clip capsule.

The blue arrow demonstrates the proximal tube and the black arrow demonstrates the distal tubal segment.

 

 

Isolated pigmented endometriosis and beginning of distal tubal segment

pigmented endometriosis involving fallopian tube after tubal ligationThis photo demonstrates isolated pigmented endometriosis with healthy tubal segments and no visual evidence of fibrosis of the tubal muscularis.

The black arrow demonstrates endometriosis underneath the distal tubal segment.

 

 

 Deep nodular endometriosis inside Broad ligament

Endometriosis-of-the-nodular-infiltrative-typeThis patient underwent tubal coagulation (burning) type tubal occlusion.

The endometriosis was observed to be deep, nodular, and mostly inside the Broad ligament. The endometriosis is located underneath the mid-segment of the proximal fallopian tube as demonstrated by the black arrow.

 

 

Pigmented nodular endometriosis

endometriosis-diagnoses-after-a-patients-tubes-were-tiedThis patient underwent ligation and resection (tying and cutting) type tubal occlusion.

Nodular, pigmented, deep infiltrative endometriosis was observed underneath the distal tubal segment. This is often removed during the tubal repair and during removal ‘chocolate type fluid’ associated with endometriosis is often discovered.

 

 

Ovarian endometriosis observed during tubal reversal surgery
Could tubal ligation have caused this endometriosis on the ovary?

Pigmented superficial endometriosis was observed on the ovarian capsule during tubal reversal surgery. This patient had previously undergone a ligation and resection type of tubal ligation.

The red arrow demonstrates the isolated endometriosis on the ovarian capsule. The black arrow demonstrates the distal fallopian tube.

 

 

Ovarian endometrioma adherent to tubal ligation site

This patient had undergone ligation and resection (tying and cutting) type of tubal ligation. She was observed to have normal pelvic anatomy at the time of tubal ligation and she did not have a history of endometriosis before her tubal ligation.

Scar tissue involving ovary and tube after tubal ligation

Ovarian endometrioma adherent to the site of tubal ligation.

At the time of tubal reversal she was discovered to have an ovarian cyst containing endometriosis (endometrioma).

The red arrow demonstrates the endometriomal cyst wall. This endometrioma was estimated to be 3cm in diameter. The red arrow and green arrow demonstrate the proximal and distal tubes. The ovary is adherent to the tubal ligation site and there is extensive thickening of the tubal muscularis with reactive fibrosis.

During surgery, the ovary was removed from its attachment to the tubal segments. The endometrioma cyst wall was removed, the fibrotic tubal ends resected, and tubal anastomosis was subsequently accomplished without difficulty.

 

 

7 thoughts on “Can Tubal Ligation Cause Endometriosis? My Personal Observations”

  1. Yasmin says:

    I had a tubal ligation during my c-section at age 26. I am now 32 and remarried and we want to have a child but I had extremely heavy periods last year and my physician performed an ablation in jan 2017. I was period free for a couple months but around September Began having a cycle again. Not as heavy as before but I have had a regular cycle for about 3-4 days each month since September. Can I still have a reversal? Is it a possibility that the lining of my uterus has grown back or wasn’t completely removed and I can still conceive after the reversal?

    1. Dr. Monteith says:

      Yasmin
      In general it is recommended that you not become pregnant after having an ablation procedure.

      Tubal reversal and pregnancy are possible if you are having regular periods of at least 3 days duration after your ablation. All pregnancies after ablation are considered high risk. Most IVF doctors will recommend using a gestational surrogate. IVF costs average $14,000 and you will have to pay the surrogate even more.

      If you are not having periods then we would not consider you a candidate for reversal. There is no medical treatment to make your periods return.

      Ablation will decrease the chance of pregnancy because it permanently damages the lining and muscle of the uterus.

      If your periods are light then you do have some functioning endometriumm but we are not always certain if it is enough to allow for pregnancy. There is no accurate way to be certain.

      We cannot provide an accurate percentage about the success of women getting pregnant after reversal with a prior ablation because there are no large scale studies looking at this. We have had women become pregnant naturally after tubal reversal with a prior ablation but don’t have a large enough group of these patients to provide meaningful statistics.

      Studies looking at women who have become pregnant after ablation show that about 50% will miscarry and about 50% will have live born babies.

      You should read these six articles I wrote about ablation, reversal, and the risks of pregnancy: Tubal Reversal and Ablation

      The ablation will decrease the chances of pregnancy but if you are having regular monthly periods of at least three days duration then pregnancy is certainly possible. If you are not having regular periods then I would advise against a reversal because pregnancy is not likely.

      In general pregnancy is not recommended after ablation because each pregnancy is at higher risk; miscarriage, growth restriction, early delivery, c-section and adherent placenta. The literature suggests pregnancies are at higher risk but many will do well.

      It is possible to become pregnant after having an endometrial ablation and then a tubal reversal and have a healthy pregnancy if you are having regular periods of at least three days duration every month. Please call us at (919)977-5050 if you have any additional questions about tubal reversal.

      To be considered a candidate by our office you need to be having regular periods (every month) and these periods need to last for at least three days.

      All patients with ablations need a consult with me (Dr Monteith) either by phone or in person before they can schedule reversal surgery.

  2. Amanda says:

    I had clamps put in 2012 due to the fact I couldn’t take birth control etc it messed my body up too much. But now I’m regretting it. I have never had period issues till I got clamped now the pain and issues have taken me to er etc. I had my kids with no meds but this pain is different. Is there anything that can be done

    1. Dr. Monteith says:

      Amanda
      Tubal clips or tubal clamps can be an excellent tubal ligation to reverse….even at 40 years of age.

      The chance of pregnancy could be as high as 80%. We charge $6,400 (total for the entire surgery) plus $125 to schedule. Although this may sound expensive, the alternative treatment is in vitro fertilization (IVF). A single cycle of IVF averages $14,000 and is about 38% successful. Call us at (919) 968-4656 8am to 5pm eastern standard time and we would be happy to speak with you.

      The following link will answer most of your questions about reversal. This is the MOST HELPFUL INFORMATION to read when considering reversal at our office. Each question has a link to more information about the question: Frequently asked questions about tubal reversal

  3. Rebecca says:

    I had my tubes done c-section i had problems they cut them and tied what im trying to understand is why after two years im still in pain it feels like i have an infection in my tubes please help me undrrstand

  4. Amanda says:

    The doctors tied my tubes using clips (I think) during my c-section with my son in 2012. My life has changed and I am now married to a wonderful man who I want to have more children with. If I have the reversal and you see something wrong in there (like endometriosis) during the surgery do you fix it all right then or do I have to have another surgery that costs more? We have gotten the money and are ready to have the surgery but I don’t want any surprises. I don’t think I have endometriosis but I have had a lot of issues since I got my tubes tied and I just really don’t want our dreams of having a baby shattered. Thank you for your time!

    1. Dr. Monteith says:

      Amanda

      Tubal clips are excellent for reversing and your chance of pregnancy could be as high as 80% to 90%. Patients schedule, travel to see us, and spend 2 nights and 3 days in Raleigh NC. We do your preoperative visit the first day, surgery the second, and your post op visit the third day. This is outpatient surgery. Please give us a call at (919)968-4656 if you want to talk more about tubal reversal.

      You will find that the link below to our Frequently Asked Questions will answer most of your questions about surgery at our center. You are welcome to send your reports to our office for a free evaluation.

      The following link will answer most of your questions: Frequently asked questions about tubal reversal

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