Sterilization failure,sterilization reversal,and pregnancy after sterilization reversal in Quebec

OBJECTIVE: 1). To determine the likelihood of sterilization reversal and of subsequent sterilization after sterilization reversal among men and women and 2). to examine the likelihood of pregnancy after sterilization (contraceptive failure) and of pregnancy after sterilization reversal. METHODS: Payment data from the Quebec provincial health insurance system were obtained for each person undergoing vasectomy or female sterilization from January 1, 1980 to December 31, 1999 and linked through a unique identifying number for each person. Using standard techniques of survival analysis, we computed the cumulative probability of experiencing each of six events. RESULTS: Among women, 0.9% (of 311960) experienced a pregnancy after sterilization, 1.8% (of 321929) obtained a reversal after sterilization, 61% (of 4369) achieved a pregnancy after sterilization reversal and 48% achieved a delivery; 23% (of 4677) obtained a subsequent sterilization after reversal. Among men, 2.4% (of 310827) obtained a reversal after vasectomy and 18% (of 6694) obtained a subsequent vasectomy after reversal. All of these risks were much higher among those in the youngest age groups. CONCLUSION: Sterilization reversal and pregnancy after sterilization are not rare. Relatively high rates of reversal among the youngest age groups suggest a need for better counseling about alternative contraceptive strategies.     

Endoscopic sterilization reversal]

In animal experiments a new technique for tubal reanastomoses has been developed, applicable endoscopically. The first results in humans indicate that this new technique may be an alternative to "classical" microsurgery in selected cases. But more data are necessary to evaluate the role of this new method in the field of reconstructive tubal surgery.     

Microsurgical reversal of female sterilization

Between 1979 and 1985, 25 consecutive, unselected women (age 28-40 years, median 34) underwent microsurgical tubo-tubal anastomosis for reversal of sterilization. The overall pregnancy rate was 44%. The incidence of pregnancy was correlated to the tubal length after reversal. Of 12 women with tubal lengths exceeding 5.5 cm, 8 (67%) became pregnant. Of the 13 women with tubal lengths under 5.5 cm only 3 (23%) conceived (p less than 0.04). There was no significant correlation between pregnancy rate and age, interval since sterilization, or the sterilization procedure itself.     

Fertility preservation and pregnancy outcome after malignancy

PURPOSE OF REVIEW: The overall survival and cure rates of patients with childhood and adult malignancies have improved dramatically, but cancer treatment can be associated with diminished reproductive potential. However, research on the preservation of fertility in these patients has given patients new options. This article discusses the mechanisms of reproductive failure after cancer therapy and the currently available fertility preservation strategies. RECENT FINDINGS: Ovarian transposition is still a viable option if radiotherapy is to be used alone. Modifications in assisted reproductive technology that decrease peak estradiol levels are ideal for breast cancer survivors. Embryo freezing technology offers excellent pregnancy rates. Oocyte freezing is available for women without a partner, but there is more limited experience with this technique. Understanding the concepts of graft function after the autotransplantation of frozen-thawed ovarian tissue has resulted in great strides in the technical requirements for success. SUMMARY: Gonadotropin-releasing hormone analogues are the only available medical protection means for gonadotoxic chemotherapy. Assisted reproductive technology offers excellent results, but the protocols require a delay in implementing chemotherapy. Despite recent reports of embryo development after the transplantation of cryopreserved-thawed ovarian tissue, clinical experience is limited and the technique remains experimental.     

Fertility outcome: long-term results after laparoscopic myomectomy

From 1991 to 1998 ,29 patients desiring a pregnancy underwent laparoscopic myomectomy for symptomatic myomas measuring 5.4 ± 3.6 cm (mean ± SD) (median 5; range 1-9). The overall rate of intrauterine pregnancy was 65.5% (19 pregnancies; two patients had two pregnancies each). Results were analyzed in relation to different preoperative clinical conditions. Out of nine patients with other infertility factors associated with uterine myomas ,three (33.3%) became pregnant; out of 10 infertile patients with no other associated infertility factors ,seven (70%) became pregnant; out of 10 patients to whom myomectomy was performed for the rapid growth of the tumor or for myoma encroaching on the cavity ,nine (90%) had a pregnancy. Nine patients (73.4%) had a Cesarean section (one twice) ,four (26.6%) had spontaneous vaginal delivery ,one patient had a serious placental failure at the 28th week ,and four patients (19%) miscarried. Two pregnancies are still in progress (one in a patient with previous miscarriage). Out of 21 pregnancies ,the viable term delivery rate was 57.14%. No uterine ruptures were observed. The pregnancy rate after laparoscopic myomectomy was similar to that reported in other studies after laparotomic myomectomy. It is concluded that laparoscopic myomectomy is a reliable procedure even in the presence of multiple or enlarged myomas. Moreover ,our pregnancy rate and pregnancy outcome seem to indicate that both desire for pregnancy and infertility prior to surgery should not be exclusion criteria for the laparoscopic approach.     

Characteristics of women requesting reversal of sterilization

For a definition of the characteristics of women who request reversal of sterilization, 180 such women were compared with 180 women apparently satisfied with sterilization. Women who requested tubal reversal were younger at the time of sterilization, began and completed their families at an earlier age, and were of lower socioeconomic status than those who did not request reversal of sterilization. Women requesting reversal of sterilization had a significantly higher incidence of gynecologic clinic visits after and mental health clinic visits before and after sterilization. Thirty-five women requesting reversal of sterilization were compared with 35 control women by administration of the Minnesota Multiphasic Personality Inventory (MMPI). Higher MMPI scores on the hysteria and psychasthenia scales were noted in women requesting tubal reversal.     

Characteristics of patients requesting reversal of sterilization

With the increased number of female patients seeking sterilization and the good chance of successful reversal using modern microsurgical techniques, it can be anticipated there will be a rise in the number of patients requesting reversal of sterilization. We have studied the characteristics of 36 patients who requested reversal of sterilization at the Royal Infirmary, Edinburgh, in the last five years. The majority of patients requested reversal on the basis of a new relationship. Other reasons included sexual problems and child death. Eighteen of the patients had clear evidence of marital disharmony at the time of sterilization. Seven of the patients had been admitted to hospital with a drug overdose since being sterilized.     

Profile of women requesting reversal of sterilization

One hundred consecutive patients requesting reversal of sterilization have been analyzed. At the time of sterilization 52% were 25 years old or under and 89% were 30 years old or under. Fifty-three patients were not in a stable marital relationship. The mean number of children per patient was 2.39. Two-thirds of the 47 patients who underwent pueperal sterilization regretted their decision within the 1st year. Twenty-six percent of the patients felt psychologically adversely affected by the procedure. The reason for requesting reversal of sterilization in the majority (63%) was a change in marital status. Other reasons were crib death (17%), desire for more children (10%), psychologic factors (6%) accidental tragedies (4%).     

Factors influencing success or failure after reversal of sterilization: a multivariate approach

Reversal of sterilization was performed in 215 patients after unipolar coagulation, Fallope ring or clip sterilization, or bipolar coagulation or a Pomeroy sterilization. All patients had a follow-up of at least 1 year. Prognostic variables were derived from the previous history, the preoperative fertility assessment, and the actual operation. Some variables were combined into a fertility reducing factor. A first selection was performed by comparing the preoperative and perioperative variable scores of the successes (defined as all intrauterine pregnancies within 1 year after surgery) with those of the failures (no intrauterine pregnancy within 1 year). Eight variables appeared to have prognostic potential. Taking account of the inter-relations of those variables by using logistic regression analysis, the localization of the anastomosis, the number of anastomosed tubes, and the presence of a fertility reducing factor were selected as the most predictive ones. Using this logistic model, an estimate of the pregnancy outcome could be calculated for each individual patient.     

Contraception and voluntary sterilization: male sterilization and the possibility of reversal

Vasectomy is a simple and safe procedure, regularly done on an outpatient basis. Since spontaneous recanalization of the vasa deferentia is always possible, researchers have experimented with other means of surgical obstruction of the vasa; such experiments, which involved silastic plugs, intravasal threads, tantalium clips, and hard or soft valves, have not been very successful. Together with an increased demand for vasectomy goes an increased demand for vasectomy reversal. Vas reanastomosis is an extremely difficult and lengthy surgical procedure; failure is usually due to anatomical and/or functional causes related and consequent to the previous vasectomy. If reversibility is surgically successful in 60% of cases, the functional success of the procedure is only about 40%. Hence the importance of sound judgment, maturity and objective counseling prior to sterilization.     

Fertility outcome after tubal anastomosis by laparoscopy and laparotomy

STUDY OBJECTIVE: To evaluate fertility outcome and benefit of laparoscopic tubal anastomosis compared with laparotomy. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Eighty-one women requesting reversal of sterilization. Fertility outcome was analyzed in 76 patients for a minimum of 6 months. INTERVENTION: Laparoscopic tubal anastomosis in 37 women and abdominal tubal anastomosis in 44. MEASUREMENTS AND MAIN RESULTS: In both groups anastomosis was performed in two layers with four stitches using microsurgical technique. Overall pregnancy rates were 80.5% in the laparoscopy and 80.0% in the laparotomy group. The mean interval from operation to pregnancy was similar in the two groups (p = 0.9). Mean operating time was significantly longer for laparoscopy (201.9 +/- 33.8 min) than for laparotomy (148.7 +/- 32.5 min), including diagnostic laparoscopy. However, mean hospital stay was shorter for laparoscopy than for laparotomy (3.3 +/- 2.0 vs 6.1 +/- 0.6 days, p <0.05). CONCLUSION: Laparoscopic tubal anastomosis is less invasive and could be an alternative to laparotomy for reversal of tubal sterilization. Advanced laparoscopic equipment and much experience could enhance the pregnancy rate and reduce operating time.     

Fertility outcome: long-term results after laparoscopic myomectomy.

From 1991 to 1998, 29 patients desiring a pregnancy underwent laparoscopic myomectomy for symptomatic myomas measuring 5.4 +/- 3.6 cm (mean +/- SD) (median 5; range 1-9). The overall rate of intrauterine pregnancy was 65.5% (19 pregnancies; two patients had two pregnancies each). Results were analyzed in relation to different preoperative clinical conditions. Out of nine patients with other infertility factors associated with uterine myomas, three (33.3%) became pregnant; out of 10 infertile patients with no other associated infertility factors, seven (70%) became pregnant; out of 10 patients to whom myomectomy was performed for the rapid growth of the tumor or for myoma encroaching on the cavity, nine (90%) had a pregnancy. Nine patients (73.4%) had a Cesarean section (one twice), four (26.6%) had spontaneous vaginal delivery, one patient had a serious placental failure at the 28th week, and four patients (19%) miscarried. Two pregnancies are still in progress (one in a patient with previous miscarriage). Out of 21 pregnancies, the viable term delivery rate was 57.14%. No uterine ruptures were observed. The pregnancy rate after laparoscopic myomectomy was similar to that reported in other studies after laparotomic myomectomy. It is concluded that laparoscopic myomectomy is a reliable procedure even in the presence of multiple or enlarged myomas. Moreover, our pregnancy rate and pregnancy outcome seem to indicate that both desire for pregnancy and infertility prior to surgery should not be exclusion criteria for the laparoscopic approach.     

Fertility and obstetric outcome after conservative management of placenta accreta

Objective

To determine the fertility and obstetric outcomes after conservative management of placenta accreta.

Methods

A retrospective observational cohort study of all identified cases of placenta accreta from 1993 to 2007 in 2 tertiary university hospitals in France. For patients treated conservatively, maternal and fetal morbidity, reproductive function, fertility, and subsequent pregnancies were recorded.

Results

During the study period, 46 patients were treated by conservative management; 6 patients underwent a secondary hysterectomy. Of the remaining 40 patients, 35 were followed up for a median of 65 months (range 18-156 months). Patients resumed their menstrual cycles after a median of 130 days (range 48-176 days). Menses were irregular in 11 patients (31%), but none had amenorrhea. Twelve of the 14 patients desiring another pregnancy achieved a total of 15 pregnancies; 2 patients had recurrent placenta accreta. Five spontaneous abortions and 1 termination of pregnancy occurred during the first trimester. The median term at delivery was 37 weeks (range, 35-40 weeks). Four patients delivered prematurely.

Conclusion

Conservative management of placenta accreta can preserve fertility, although the risk of recurrent placenta accreta appears to be high.     

Peritoneal endometriosis in women requesting reversal of sterilization

Seventy-six women requesting reversal of sterilization underwent at least 1 operative procedure during a 27-month period, and 14 (18.4%) were found to have pelvic endometriosis. The endometriosis patients were noted to have had significantly fewer pregnancies (1.8 versus 2.9, P less than 0.01) before sterilization than those without endometriosis, but the two groups did not differ significantly in mean age (30.8 versus 30.3 years), type of sterilization or in mean number of years since sterilization (5.0 versus 5.5 years). In only two individuals were proximal tubal segment fistulas found at the time of reversal, and neither had endometriosis. We conclude that pelvic endometriosis is more common in patients with bilateral tubal occlusion than previously suspected and that its presence indicates that endometriosis implants can persist for prolonged periods of time, can give rise to new implants, or do not require the tubal reflux of menstrual debris to form.     

Microsurgical reversal of sterilization: a six-year study

A prospective study of 113 personal consecutive microsurgical reversals of female sterilization during the 6-year period from 1979 to 1984 was carried out to determine factors affecting the pregnancy rate. The sterilizations were performed by laparoscopic unipolar coagulation in 54% of the patients, by the Pomeroy technique in 28%, by fimbriectomy in 8%, by the Irving operation in 5%, and by clips or rings in 4%. In the group with no minimum follow-up period, 50% had intrauterine pregnancies and 5% had ectopic gestations. Eighty-nine patients had at least 12 months of follow-up after reversal surgery. This group is studied in detail. Factors affecting the pregnancy rate were length of tube, type of sterilization performed, anastomotic site, and availability of both tubes for reconstruction. Age, parity, and interval from sterilization to reversal surgery did not affect the pregnancy rate. Fifty percent of the intrauterine pregnancies were conceived within 6 months of reversal surgery.     

The fate of women requesting reversal of tubal sterilization

Although it was not possible to identify by simple demographic measurements those women who would elect not to pursue full investigation, this study has highlighted the high drop-out rate of women requesting reversal, and suggested that discussion with the couple at the first visit is a valid procedure, particularly if it allows as many as one-third of patients to elect not to proceed to invasive procedures. Finally, this study underscores that when gynecologists are counseling patients with respect to sterilization and the question of reversibility is opened, the success rate is not in excess of 50% when it is considered a function of the number of women regretting reversal rather than a function of women who undergo surgery.     

Tubotubal anastomosis for reversal of female sterilization in Thailand

From September 1979 to December 1983, 168 women requested sterilization reversal. Forty-four of them were selected for tubotubal anastomosis, employing a microsurgical technique. The mean age was 28.7 years (range, 22-37), the mean number of pregnancies was 2.0 (range, 0-3), and the mean number of living children was 1.6 (range, 0-3). The main reason for the reversal request was remarriage (63.63%). The overall crude rate of full-term intrauterine pregnancies resulting in live births was 61.4%. The ectopic pregnancy rate was 4.5% and the abortion rate, 2.3%. Three cases were lost to follow-up. Life-table analysis revealed a cumulative pregnancy rate of 77% one year after surgery and 80% two years after surgery.     

Fertility outcome after treatment of retained products of conception: a systematic review

Background

Treatment of retained products of conception (RPOC) can be expectant, medical or operative. Surgical removal of RPOC may lead to intrauterine adhesions (IUA) and Asherman’s syndrome.

Objective

To evaluate how treatment options for RPOC affect future fertility by means of a systematic review.

Search strategy

MEDLINE, EMBASE, The Cochrane Library, and clinical trial registers were searched, and reference lists were scanned.

Selection criteria

Randomised controlled trials (RCT) comparing different treatment options for RPOC (conservative, medical or surgical treatment, including curettage and/or hysteroscopic techniques, with or without application of anti-adhesion therapy), in women of reproductive age, were eligible for inclusion.

Data collection and analysis

Reviewers independently performed data extraction and quality of evidence assessment. For dichotomous variables, results were presented as risk ratio (RR) with 95% CI.

Main results

Two studies were included. Nonsignificant differences were observed between the use of an anti-adhesion barrier gel versus no treatment after operative hysteroscopy in IUAs (RR 0.32, 95% CI 0.04 to 2.80, P value?=?0.30) and clinical pregnancy (RR 2.22, 95% CI 0.67 to 7.42, P value?=?0.19), and between hysteroscopic morcellation versus loop resection in IUAs (RR 0.86, 95% CI 0.06 to 13.12, P value?=?0.91).

Conclusion

There is insufficient evidence on how different treatment options for RPOC affect future reproductive outcomes. Results from ongoing RCTs are needed to guide clinicians towards choosing the best treatment.

     

Microsurgical reversal of female sterilization. Long-term follow-up of 117 cases

A prospective study of 117 consecutive microsurgical reversals of female sterilization from April 1981 to December 1984 was carried out to determine which factors affected the pregnancy outcome. Nylon sutures, 8-0, were placed through the muscularis and mucosal layers. A short abdominal incision was made. The patients were followed for 3.5 to 7.0 years. The term delivery, intra-uterine pregnancy, spontaneous abortion and ectopic pregnancy rates were 81.2%, 83.8%, 1.7% and 1.7%, respectively; two ectopic pregnancies occurred 14 and 24 months after the reversal procedures. We found that the time interval between sterilization and reversal and the methods of sterilization affected the pregnancy outcome. The success rate with intervals of less than five years was much higher than with intervals of more than five years; Pomeroy cases were more reversible than Uchida cases. We did not observe any influence of the anastomosis site on the pregnancy results. The term delivery rates for isthmus-isthmus, isthmus-ampulla and ampulla-ampulla anastomoses were 78.8%, 80.0% and 84.6%, respectively. Patients should be followed for two years at least to determine the pregnancy outcome as well as the occurrence of ectopic pregnancy.