Sterilization failures following fibrectomy

Four of 272 patients with bilateral fimbriectomy became pregnant. In each of the four cases the distal end of the Fallopian tubes was closed but a tubo-peritoneal fistula could be observed in the antimesenterial part of the tube - immediately proximal of the former ligatures. These failures of sterilization were all found in a group of 16 patients, in which VICRYL 2/0 was used for ligation after resection of the fimbriated end. In all the other cases of fimbriectomy Chromcatgut 2/0 was used.     

Sterilization failures and their causes

To say that a sterilization failure rate is expected does not answer why. Forty-seven cases of repeat sterilization have undergone such surgical and pathologic scrutiny. Resection methods failed most frequently because of spontaneous reanastomosis or fistula formation. Fimbriectomy was particularly vulnerable to reanastomosis because the fimbria ovarica was not removed. Mechanical devices failed when the device was defective, placed improperly, or placed in an improper location. Tissue damage was evident but incomplete when the bipolar electrocoagulation method failures were reviewed, and the endosalpinx remained viable. Unipolar method injuries, in contrast, were complete; they failed by fistula formation. Thus bipolar method failures may occur because of the limited range of electrical power available when using bipolar generators. Some sterilization failures are preventable, but many are not. When medicolegal questions arise, these findings may help answer the question, Why?     

Pregnancy after tubal sterilization with bipolar electrocoagulation. U.S. Collaborative Review of Sterilization Working Group.

OBJECTIVE: To determine risk factors for pregnancy after tubal sterilization with bipolar electrocoagulation. METHODS: A total of 2267 women who had bipolar electrocoagulation were followed for up to 8 to 14 years as part of a multicenter, prospective, cohort study conducted in medical centers in nine United States cities. We used proportional hazards analysis and cumulative life-table probabilities to assess pregnancy risk in these women. RESULTS: The 5-year cumulative probability of pregnancy for women sterilized in 1978-1982 was 19.5 per 1000 procedures (95% confidence interval [CI], 12.2, 26.9); the comparable probability for women sterilized in 1985-1987 was significantly lower, 6.3 per 1000 procedures (95% CI, 0.0, 13.5) (one-tailed P = .01). Women enrolled in 1985-1987 who had fewer than three sites of coagulation had a probability of failure of 12.9 per 1000 procedures (95% CI, 0.0, 38.0); by contrast, women who had three or more sites coagulated had a probability of failure of 3.2 per 1000 procedures (95% CI, 0.0, 9.6) (one-tailed P = .01). CONCLUSION: The long-term probability of pregnancy after tubal sterilization with bipolar coagulation was very low when three or more sites of the fallopian tube were coagulated. Bipolar coagulating systems can be highly effective for sterilization when the fallopian tube is coagulated adequately.     

Reducing bipolar sterilization failures

Many bipolar sterilization failures have occurred because of incomplete desiccation of the endosalpinx. This study compared the effect upon human fallopian tubes of different waveforms of electrical energy at advancing power settings. When the Valleylab SSE2-L generator was attached to the Kleppinger bipolar forceps, complete desiccation was confirmed with the power set at 25 W in a cutting waveform. Other waveforms (coagulation and blend) failed to complete the task at the same power setting. An inline current meter assures the operator that all the available energy is delivered. This information should help to reduce bipolar sterilization failures.     

Morbidity and vaginal tubal cautery: a report and review

Vaginal tubal sterilization was once the procedure of choice for interval sterilization. This technique fell out of favor in part because of a perceived increase in morbidity over the evolving laparoscopic techniques. Complications should be minimized by the advent of routine antibiotic prophylaxis and improved operating techniques that allow shorter procedure times. We retrospectively reviewed 240 vaginal tubal sterilization procedures performed by a single physician. Long-term follow-up (more than 5 years) was available in over half the study group (52%). Half of all operations were completed in 12 minutes or less, with an average time of 14.5 minutes. The planned vaginal procedure was completed in all but two cases, both of which required laparotomy secondary to dense adhesions. Median estimated blood loss was 20 mL. No postoperative infection was encountered. These data suggest that vaginal tubal sterilization may still be a safe alternative for interval sterilization.     

Laparoscopic tubal sterilization: monopolar and bipolar electrocoagulation

The study describes 73 interventions of female sterilization obtained laparoscopically by monopolar or bipolar electrocoagulation. Indications for sterilization were essentially medical; 86.2% of patients were above 30, and average parity was over 3. Operative procedures went very smoothly; there were 5 cases of complications: 2 emphysemas caused by pneumoperitoneum, and 3 cases of hemorrage of the mesosalpinx. Hospital stay never exceeded 4 days. No pregnancies were reported, and menstrual cycles and sexual life were quite normal after the procedure. The article also reviews the monopolar electrocoagulation.     

Method failures of laparoscopic tubal sterilization in a residency training program. A comparison of the tubal ring and spring-loaded clip.

A prospective, randomized study of 365 women undergoing interval laparoscopic tubal sterilization in a residency training program was undertaken to compare method failures. Two occlusive techniques were compared, the spring-loaded clip (Hulka-Clemens) and the tubal ring (Falope Ring). Patients were randomized to either Falope Rings or Hulka-Clemens clips as the primary method. Demographic characteristics, educational level and operator experience were similar in the two groups. Follow-up at an average of 16 months (range, 6-24) revealed eight pregnancies (4.5%) in 176 women in the clip group and five pregnancies (2.6%) in the ring group. The Hulka-Clemens clip and the Falope Ring have similar incidences of method failure when employed by inexperienced operators. We question the usefulness of chromopertubation utilizing methylene blue dye to ensure proper placement of the occlusive device.     

Ovarian reserve testing before and after laparoscopic tubal bipolar electrodesiccation and transection

Objective

To find out whether tubal sterilization leads to loss of ovarian reserve, we assessed the hormonal and ultrasonographic parameters of ovarian reserve in women who underwent laparoscopic tubal sterilization by bipolar electrodesiccation and transection.

Study design

In this preliminary study, laparoscopic tubal sterilization was performed on 49 healthy women who had voluntarily requested elective surgical sterilization. Among the current ovarian reserve indicators, in the early proliferative phases, preoperative (baseline) and postoperative (third month) serum follicle-stimulating hormone (FSH), estradiol (E2), and anti-Mullerian hormone (AMH) levels, ovarian volume, and antral follicle counts (AFCs) were determined. Analysis of these hormonal and ultrasonographic parameters of ovarian reserve preoperatively and postoperatively was the main outcome measure.

Results

Preoperative and third-month postoperative FSH, LH, E2, and AMH levels did not reveal statistically significant differences (p = 0.101, p = 0.180, p = 0.254, and p = 0.079; respectively). The ultrasonographic indicators of ovarian reserve did not change in terms of total ovarian volume and total AFC (p = 0.793 and p = 0.098, respectively).

Conclusions

Short-term follow-up study results revealed a slight but non-significant change in the current ovarian reserve markers, especially in the AMH levels.     

Reproductive outcome after fallopian tube canalization and microsurgery for bipolar tubal occlusion

Surgical therapy for coexistent proximal and distal obstruction has consisted of combined proximal (reimplantation of reanastomosis) and distal (salpingostomy) repairs. Data suggest that successful relief of proximal obstruction by fluoroscopically guided tubal canalization (FTC) may be achieved in 60% to 95% of cases. We studied the use of FTC as a preoperative adjunct in 14 patients with coexistent proximal tubal obstruction (PTO) and distal tubal obstruction, progressing to surgical repair of distal disease if proximal patency was achieved. Unilateral (9/14) or bilateral (5/14) PTO was demonstrated on at least one hysterosalpingogram (HSG) and during chromotubation performed as part of the diagnostic laparoscopy. FTC was successful in four patients (28%). HSG revealed proximal reocclusion in two patients. Two patients had persistent proximal patency and underwent distal salpingostomies and adhesiolysis for mild hydrosalpinges and pelvic adhesive disease. No pregnancies have been achieved after 12 and 18 months follow-up. The lower patency rate and higher recurrence rates of PTO when compared to data of prior studies suggest that in vitro fertilization, though more costly, ultimately may represent the most expedient and effective method of management of coexistent proximal and distal tubal disease.     

Proximal tubal obstruction associated with tubal schistosomiasis.

The gynecologic consequences of schistosomiasis may range from minimal inflammation of tubal serosa to more intense reactions involving the periadnexal regions. Complete obliteration of the tubal lumen has not been described. We describe a case of proximal tubal obstruction associated with tubal schistosomiasis.