Tubal recanalisation-microsurgical tubal reversal anastomosis

INTRODUCTION

Tubal recanalization is a microsurgical technique which needs significant training and expectation in handling the tissues meticulously. The success depends on patience, perseverance, and perspiration on the part of the surgeon.¹ In recent years, an increasing number of couples of lower age and lower parity have begun to request for sterilization. When these couples experience the death of a child or if they divorce or remarry following the death of the husband, they may wish to be able to have another child. The availability of microsurgical recanalization procedures would bring hope to those in need of these services and would improve the confidence of clients who are acceptors of voluntary sterilization. Following a tubal ligation, there are usually two remaining fallopian tube segments.² The proximal tubal segment that emerges from the uterus and the distal tubal segment that ends with the fimbria next to the ovary. After opening the blocked ends of the remaining tubal segments, a variety of microsurgical techniques are utilized to recreate a functional tube. The newly created tubal openings are drawn next to each other by placing sutures in the connective tissue that lies beneath the fallopian tubes.³ The retention suture prevents the tubal segments from pulling apart while the tube heals. Microsurgical sutures are used to precisely align the tubal lumens (inside the canal of the tube), the muscular portion (muscular external), and the outer layer of the tube.⁴ Most surgeons try to avoid the use of stents which can damage the delicate cilia that line the tube and create the flow of fluid that is needed to push the egg and embryo into the uterus. Other surgeons use a narrow flexible stent to gently thread through the tubal segments or into the uterine cavity in order to line up the tubes in order to reconnect them. In either case, once the microsurgical repair is completed dye is injected through the cervix into the uterus and out through the tubes to ensure that the fallopian tube is open from the uterine cavity to its fimbrial end.⁵ The surgeons who use stents then gently withdraw them from the fimbrial end of the tube after the repair is completed. Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure using small, specially-designed instruments to repair and reconnect the fallopian tubes.⁶

METHODS

Totally 65 female patients were included in the study. The study was conducted in the department of plastic surgery, Government Mohan Kumaramangalam medical college hospital, from 2016-2018. Authors have the patients for past 18 years including post tubectomy patients with is variable age and duration after sterilization and all methods of sterilization except fimbriectomy. For all cases, we have done all basic investigation, USG, and HSG.

Exclusion criteria

• • Women aged above 39 years,
• • Women with the obvious pelvic inflammatory disease, endometriosis or fibroid as a cause of infertility,
• • Women with ovulatory disturbances,
• • Women with any contraindications to pregnancy or surgery.

Technique/ procedure

Under spinal or epidural anesthesia through abdominal incision abdomen opened, uterus delivered, tubes with ovaries are delivered, ligation site identified and fresh the edges. Haemostasis obtained with 100%, under loop 4X magnification. Tubal anastomosis was done with 8-0 prolone in layers. Two layers first layer by intermittent sub mucosal layer and serosal layer, at the same time patency identified and confirmed before taking a bite. I will not use any stent for the patency of the lumen. At the ends of the anastomosis patency confirmed by introducing probes from fimbrial end across the anastomosis site another side also done the same procedure. During procedure inj. Hydrocortisone 100 mg IV given. sexual intercourse was allowed after two months of surgery. Three months postoperatively HSG levels were performed to ascertain the status of tubal patency. Subsequently, these patients were followed up three months for the evidence of pregnancy up to five years. Pregnancy rate was correlated with the method used for previous tubal ligation, the age of the patient at the time of sterilization reversal, the time interval between sterilization and reversal, length of the reconstructed tubes, anatomical site of the anastomosis.

Stastical analysis

Chi-square/ fisher exact test has been used to find the significance of study parameters on a categorical scale between two or more groups.

RESULTS

Totally 65 patients were in regular follow up. 19 patients were between 20-24 years. 30 were between 25-29. 16 were between 30-34. Age group 25-29 were more in the study. Age has a definite effect on pregnancy rate because after the age of 35 while the incidence of genetic abnormalities and maternal complications tends to increase, this age is considered a cutoff point for any tubal reconstruction procedure.

59 patients had less than 2 parity, 7 had less than 3. In present study most reversal seekers (97.5 %), were para two or less this is not surprising considering in our hospital population, the parity is low.

Total 20 patients had puerperal sterilization. 30 with laparoscopic, 15 with concurrent LSCS. the present study showed a success rate of 50% in women who had undergone laparoscopic sterilization as compared to 35% in women following reversal of Pomeroy technique. the success in case of mechanical occlusion of uterine tubes with is higher as smaller amounts of tubal segments are excised

Out Of 65 Patients 30 with isthmo-isthmic, 18 with isthmo ampullary, ampulla-ampullary, 8 with infundibula-ampullary, cuff salpingostomy. The site of tubectomy and hence the site of recanalization is an important factor in determining the results of tubectomy reversal. It is suggested that the isthmus of the fallopian tube is an ideal site for sterilization considering the possible need for reversal.

In the study above 6cm were in 50 patients, 4-6cm length in 28 cases, less than 4cm were 5 cases. the These the results highlight the significance of the type of sterilizer action procedure on the prospects for pregnancy following reversal surgery. Mechanical procedures (laparoscopic ring occlusion) that produce minimal damage to the isthmus of the tube are the most favorable. Though the patient with the tubal length of <4cm conceived, the number is too small to comment.

The live birth rate was 76.3% and the abortion rate was 9.5%. The rate of ectopic pregnancy being 4.7% and ongoing pregnancy rate of 9.5% in this study. Live birth in 20 patients, abortion 2 patients. Ongoing pregnancy is two. Ectopic pregnancy is one and overall success rate in 45 patients.

DISCUSSION

Reconstructive tubal surgery was at one time the only treatment option for infertile women with damaged fallopian tubes. The overall risk of reconstructive surgery is small and includes the recognized complication of anesthesia and surgery. Surgery, if successful, offers multiple cycles in which to achieve conception and the opportunity to have more than one pregnancy.⁷ The abortion rate subsequent to reconstructive tubal surgery is not increased over that of the normal population. The live birth and ectopic pregnancy rate depend on the specific nature of the disease and the extent of the tubal damage. The request for reversal of sterilization usually come from couples who have remarried, tend to be younger, have fewer live children, have had more abortions, less schooling, and are poor users of contraception.⁸ In these high-risk patients, counseling and time to make the decision for sterilization are essential. These women should be sterilized by a method that destroys the least tube. Haj N et al, retrospectively evaluated major reasons for the request for reversal which were a loss of children 50%, remarriage 27%, 10%.⁹

Holst et al, studied comparison between microsurgical and micro laser techniques and concluded that the carbon dioxide laser’s advantages (precision, homeostasis and the ability to preserve more normal reproductive tissue), although technically beneficial in performing microsurgical tubal reanastomosis, may not prove to be superior to conventional microsurgical technique as pregnancy rates are compared. Additional long-term studies are needed as more experience is gained to further delineate the role of the carbon dioxide laser for microsurgical tubal reanastomosis.¹⁰ Kao et al, observed that the results of microscopic sterilization reversal were comparable to the reported results of microsurgical methods. They support the contention that traumatic technique rather the microscope is important for good results. In the present study, the death of one or all children was the commonest reason for a couple to seek reversal of sterilization (80%).¹¹ In the study by Katz et al, death of a male child (64.2%) was the major reason for sterilization reversal. The most important factor to enhance the effectiveness of recanalization is the length of the reconstructed tubes Silber and Cohen, 1980 and Henderson, 1981.¹² In the present study, 97.5% had a final tubal length of more than 4 cm. The pregnancy was achieved in 61.5% of the women when the tubal length was more than 6 cm in comparison to 40.9% when the length was 4-6 cm.¹³ These results highlight the significance of the type of sterilization procedure on the prospects for pregnancy following reversal surgery. Mechanical procedures (laparoscopic ring occlusion) that produce minimal damage to the isthmus of the tube are the most favorable.^14,15

CONCLUSION

Although microsurgical reversal achieved 100% patency rate in studied patients, certain factors, like duration of sterilization, the technique of sterilization, and the length of the tube remaining after reversal, played a crucial role in deciding the pregnancy rate. Besides the magnification and atraumatic technique, tubal length >4cm and the time interval between sterilization and reversal of <5years resulted in better pregnancy rate. Although the microsurgical technique has its own limitations, its proper application has brought a ray of hope to women seeking sterilization reversal.

ACKNOWLEDGEMENTS

The author would like to thank the professors, Associate professors and Assistant professors, Department of Plastic Surgery, Government Mohan Kumaramangalam Medical College. Salem, Tamil Nadu, India for their valuable support in research work.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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