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Can Tubal Ligation Cause Endometriosis? My Personal Observations

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.


endometriosis and scar tissue from tubal ligation

Deep nodular endometriosis after tubal coagulation

Deep nodular pigmented endometriosis, fibrosis, and adhesion formation

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.


endometriosis-around-tube-after-tubes-tied

Superficial pigmented endometriosis of Broad ligament

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.


Difficult to see endometriosis after tubal ligation

Both pigmented and non pigmented endometriosis of Broad ligament.

Superficial pigmented and non pigmented endometriosis

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.


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

Deep pigmented endometriosis with surrounding fibrosis.

Deep nodular endometriosis and 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.


endometriosis caused by tubal clip

Pigmented endometriosis with Filshie clip.

Pigmented endometriosis associated with tubal clip ligation

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.


pigmented endometriosis involving fallopian tube after tubal ligationIsolated pigmented endometriosis and beginning of distal tubal segment

This 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.


Endometriosis-of-the-nodular-infiltrative-typeDeep nodular endometriosis inside Broad ligament

This 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.


endometriosis-diagnoses-after-a-patients-tubes-were-tiedPigmented nodular endometriosis

This 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.


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

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.


Scar tissue involving ovary and tube after tubal ligation

Ovarian endometrioma adherent to the site of tubal ligation.

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.

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.


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7 Comments

Tina Reply

I had my tubes removed in July now since September I’ve been having abnormal bleeding and was diagnosed with endometriosis and I’ve never had it before


    Dr. Monteith Reply

    Tina
    Endometriosis causes pain and is only reliably diagnosed at the time of surgery.


Latasha Reply

I beg to differ on the statement that women with endometriosis do not have daily pain.
When my endo symptoms were at their worst, while I didn’t have pain for 30 days straight, I did have pain for at least 3 weeks straight, prior to my period and then I was blessed to have one pain free week after my period only to have it start again. This was the norm until the endo was removed from my uterus and ovaries.
I was pain free for two years and then it started again. I had the endo removed again and was pain free for about 2 years. Now it’s been three years and I’m experiencing the worst pain ever with all sorts of abnormal bouts of bleeding etc. I’m due to have laparoscopy yet again.
Hormone treatment has been offered, however , I have Graves Disease and prior to my endo diagnosis, I was prescribed Lupron injections for 6 months and that caused me to develop full blown (for lack of a better term) Graves Disease as I was later tested and found to be a carrier of the Graves Disease gene. My experience was so debilitating that I contacted the FDA who stated that they never tested Lupron on individuals
who had the Graves Disease gene, and then they sent me what appeared to be 50 pages worth of information.
Hyperthyroidism, TED and and being a hairs width away from going into Thyroid Storm has caused me to swear off any and every synthetic hormone unless it’s to save my life literally. From taking over ten pills a day just to regulate my thyroid and Mirena IUDs to attempt to alleviate this endo pain, I’m exhausted mentally and physically. And I dread my cycle every month. And to think, all of this mess only started AFTER having my tubes tied in 2001.


Katherine Faulkner Reply

Hi so I’m 30 I have 3 kids and I got a tubal ligation a year and a half ago and now I’m having extreme lower abdomen pain sometime all day everyday, and hurts to go num 2, I’m uncomfortable all the time.. dose this seem serious? I’m not that good with Dr but my pain is pushing me, could this be a sign of endometriosis? I also was diagnosed with cysts on my ovarys almost 2and a half years ago.


    Dr. Monteith Reply

    Patients with endometriosis typically have very painful periods. They dont have daily pain.


Alexandria Reply

What are the statistics on developing endometriosis after getting your tubes tied? I am 28 years old, a mother of 4 live births, 2 miscarriages, and 4 c-sections. I have a 3 day cycle stop for a day then dark chocolate left over blood coming out for 2-3 days. In addition to pain that is about a 9. I have also had to boycott tampons due to the pain. Would you recommend a visit to the lady part dr? Or could you give me an idea of what my symptoms are presenting to you please? I had a tubal litigation almost three years ago. Recently I’ve considered having a reversal, but due to the issues I’ve been scared to find out what’s wrong. If I have a reversal would it be alright to try for one more?


    Dr. Monteith Reply

    Alexandria

    We don’t know what the chance of developing endometriosis is after tubal ligation. Likely the answer is less than 5%.

    It is always best if you see your doctor for evaluation of your problems before you consider tubal reversal surgery. If you want to become pregnant then tubal reversal is a great option.