Ectopic pregnancy following tubal sterilization

Over a 5 year period 232 ectopic pregnancies were recorded at Ullevaal Hospital in Oslo, Norway. There had been 10,294 births during this July 1976 to June 1981 period. In 3 cases tubal sterilization had been performed prior to the development of the extrauterine pregnancy. A total of 1047 female tubal sterilizations were performed during these 5 years. Almost all the sterilizations were done by laparoscopy. Different methods of sterilization were used: unipolar diathermy; spring clips according to Hulka; silicone rings; and endotherm coagulation. Each case of the 3 ectopic pregnancies, observed following tubal sterilization, is reviewed. A 36 year old patient became pregnant 3 years after diathermy sterilization. The right tube was found normal, and the pregnancy located in the lateral part of the divided left tube. 14 months following silicone ring sterilization a 26 year old patient had an ectopic pregnancy in the lateral right tube. The silicone ring was in perfect position on the left side. The medial right tube showed fibrous scarring after the ring application, but the ring was located in the mesosalpinx. A 37 year old patient was admitted to the hospital after a tubal pregnancy 10 months after diathermy sterilization. The pregnancy was in the lateral part of the tube. Both tubes had been transected, and there was a diastase of about 2 centimeters. The etiology of ectopic pregnancies is complex. It is only recently that previous sterilization has been recognized as a factor in this condition. Luteal phase pregnancies are because of a failure in the timing of the procedure and are unrelated to the procedure itself. Pregnancies resulting from operative failure range from 0-2.4/1000 sterilizations in different series. Technical failure may be caused by recanalization, fistula formation, and product failure. An important cause of ectopic pregnancy after laparoscopic sterilization is probably fistula formation that allows sperm to pass out of the uterus. Such fistulas have frequently been documented. Thus, if it is considered necessary to confirm tubal occlusion by salpingogram, this should be delayed for at least 12 weeks. As fistula formation probably is a major cause in this entity, division of the tube at the time of sterilization is neither necessary nor desirable. It is important to damage the tube in the isthmic segment and to minimize the involvement of the parametrium in the destructive process.     

Factors affecting the pregnancy rate after microsurgical reversal of tubal ligation

Objective

To evaluate the factors affecting the pregnancy rate after microsurgical reversal of tubal ligation.

Design

Retrospective clinical study.

Setting

Private practice affiliated with a tertiary care center.

Patient(s)

One hundred twenty-eight consecutive patients who underwent tubal reversal between October 1992 and May 2001.

Intervention(s)

Microsurgical tubal reanastomosis performed by a single surgeon.

Main outcome measure(s)

Subsequent pregnancy rates were evaluated with Fisher’s exact tests and logistic regression according to clinical characteristics of patients.

Result(s)

The pregnancy rate was 85.7% (54 out of 63) in patients ≤35 years of age vs. 45.5% (10 out of 22) in patients >35 years. The odds ratio (OR) between the two age groups was 7.20, with a 95% confidence interval (CI) of 2.41 to 21.55. The pregnancy rate was 85.4% (35 out of 41) in patients with body mass index (BMI) ≤25 compared with 65.9% (29 out of 44) in patients with BMI >25 (OR 3.02; CI 1.04 to 8.77). Patients sterilized ≤8 years had a pregnancy rate of 87.2% (34 out of 39), vs. 65.2% (30 out of 46) in patients sterilized >8 years (OR 3.63; CI 1.19 to 11.09).

Conclusion(s)

Age was the primary statistically significant factor affecting pregnancy rate in tubal reversal patients. Body mass index and duration of sterilization had smaller, but statistically significant, associations with pregnancy rate.     

Ectopic pregnancy in a distal tubal remnant

Ectopic pregnancy is a well-recognized complication of tubal reanastomosis (Young PE, Egan JE, Barlow JJ: Reconstructive surgery for infertility at the Boston Hospital for Women. Am J Obstet Gynecol 108: 1092, 1970 and Hodari AA, Vibhasiri A, Isaac AY: Reconstructive tubal surgery for midtubal obstruction. Fertil Steril 28: 620, 1977). We describe here, however, a case of tubal pregnancy occurring in a tubal remnant on the opposite side to a successful tubocornual reanastomosis.     

Repeated ectopic pregnancy on the tubal stump after laparoscopic salpingectomy

A 40-year-old woman who had undergone laparoscopic right salpingectomy because of a tubal pregnancy 10 years ago presented to our hospital with severe lower abdominal pain. Ectopic pregnancy with internal bleeding was suspected after evaluation. With laparoscopy, repeated ectopic pregnancy on the tubal stump was diagnosed and treated successfully.     

Falloposcopy after prostaglandin treatment of tubal pregnancy

We report on a tubal pregnancy treated with prostaglandin F₂ locally. Falloposcopy two years afterwards showed multiple, non obstructive adhesions of the tubal epithelium.     

Rupture of tubal pregnancy in the Vilnius population

OBJECTIVES: To evaluate the determinants of tubal rupture in women who suffered from ectopic pregnancy in relation to their demographic profile and medical history. STUDY DESIGN: This retrospective observational clinical study was conducted in five general hospitals in Vilnius, Lithuania. The population was composed of 879 women with surgically proven ectopic pregnancy. Tubal rupture was diagnosed at the time of surgery. Univariate and multivariate logistic regression analyses were performed to identify the risk factors for tubal rupture. RESULTS: The occurrence of tubal rupture was 29.5% (259/879). It was encountered significantly more often in women with age of > or =35 years (odds ratio 1.9 [1.3-2.8]). Patients whose EP was located in the isthmus were at higher risk of having tubal rupture (odds ratio 3.2 [2.2-4.5]) while known risk factors for EP were not associated with an elevated risk. CONCLUSIONS: Our data suggest that age of > or =35 years and implantation in the straightest segment of the tube could be associated with increased rate of tubal rupture. Of particular interest is the overall tubal rupture prevalence (29.5%) observed since these women were managed in an environment where transvaginal ultrasound equipment and quantitative assessment of beta-human chorionic gonadotrophin were not routinely available.     

The effect of tubal ligation scoring and sterilization counseling on the request for tubal reanastomosis

Objective?The aim of this study is to emphasize the role of counseling methods that are meant to decrease the request for tubal ligation reversal, such as tubal ligation scoring.

Method?This study covers 389 patients who were admitted for tubal sterilization to Çukurova University, Faculty of Medicine, Obstetrics and Gynecology Department, between 1 January 1990 and 31 December 1999. We have used the ‘Tubal ligation score’ on these 389 patients. Four hundred and seventeen patients who underwent bilateral Pomeroy type tubal ligation during cesarean section without having undergone tubal ligation scoring in the same time interval, were accepted as the control group.

Results?Laparoscopic tubal ligation (with a Yoon ring) was performed on 368 patients who had a score of 6 or higher. Twenty-one patients who got a score of 6 or lower were recounseled and another family planning method was prescribed to them. None of the 368 patients to whom tubal ligation scoring was done previous to laparoscopic tubal ligation returned to our clinic for tubal reanastomosis. Fifteen of the 417 patients (3.6%) in the control group returned to our clinic for tubal reanastomosis.

ConclusionTubal ligation scoring may decrease the ratio of patients who request a tubal ligation reversal.     

输卵管结扎对卵巢癌影响的研究

目的：比较卵巢癌不同发病年龄、体重指数（BMI）、孕产次、病理分类、组织学分级、二元论分型中输卵管结扎的比例,探讨输卵管结扎对卵巢癌的影响。方法：选取2001年6月-2013年2月在郑州大学第三附属医院和郑州大学第一附属医院妇产科就诊的189例卵巢癌患者,同期选取因子宫肌瘤、子宫脱垂就诊的209例患者作为对照组,比较两组患者的输卵管结扎比例。结果：189例卵巢癌患者中89例行输卵管结扎,209例对照组中99例行输卵管结扎。卵巢癌患者中≤44岁者的输卵管结扎比例显著低于对照组（P〈0.05）;BMI为18.5-24.9kg/m^2和≥25kg/m^2者的输卵管结扎比例与对照组比较,均无显著差异（P〉0.05）;孕产1-2次者输卵管结扎比例低于对照组（P〈0.05）,≥3次者的输卵管结扎比例显著高于对照组（P〈0.05）。卵巢浆液性癌、黏液性癌和子宫内膜样癌患者中,行输卵管结扎的比例分别为44.4%（48/108）、52.5%（32/61）和45.0%（9/20）。卵巢癌不同病理类型间的输卵管结扎比例无显著差异（P=0.593）。卵巢癌G1、G2、G3级患者中,行输卵管结扎的比例分别为50.0%（52/104）、50.9%（29/57）和28.6%（8/28）,无显著差异（P=0.104）;但G3级显著低于G1＋G2组（P=0.033）。二元论分型Ⅰ、Ⅱ型中行输卵管结扎比例分别为50.0%（52/104）和43.5%（37/85）,无显著差异（P=0.375）。结论：卵巢癌的发病机理、组织起源等可能与输卵管结扎有关。     

Ectopic pregnancy

Ectopic pregnancy is a implantation occurring elsewhere than in the cavity of the uterus, whereas nintynine percent of extrauterine pregnancies occur in the fallopian tube. The incidence of extrauterine pregnancy has increased from 0.5% thirty years ago, to a present day 1–2%. The most frequent cause of tubal pregnancy is previous salpingitis. Mortality rates for tubal pregnancies used to be approximately 1.7% in the 1970 s but dropped to 0.3% in 1980 s. Diagnosis: Using transvaginal ultrasound it is possible to obtain positive evidence of an ectopic pregnancy at a very early stage. In cases of hCG titers>2000 IU/l, intrauterine pregnancy can be diagnosed with certainty. The most important differential diagnosis of ectopic pregnancy is early intrauterine pregnancy. Clinical management and therapy: Regardless of the therapeutic strategy selected by the physician, informing the patient is a major aspect of the management of ectopic pregnancy. If surgery is considered appropriate, the patient must be informed about the nature, side effects and complications of the procedure. However, it should be remembered that in some cases, the actual chances of cure first become apparent at surgery. In asymptomatic patients with a serum hCG titer <1000 IU/l that is falling, it is appropriate to wait and watch. In clinically stable patients with an unruptured tubal pregnancy and steady hCG levels, systemic treatment with methotrexate might also be considered. In unruptured tubal pregnancy with a hCG titer between 1000 and 2500, a further therapeutic alternative is intratubal injection of prostaglandins, hyperosmolar glucose of NaCl. Generally speaking, the currently widespread laparoscopic surgical treatment of the fallopian tube hardly influences the risk of recurrence. If the gestational mass is larger, the serum hCG titer higher than the approximate limit of 2500 mU/ml and/or the tube already ruptured, surgery is usually required. Prevention: The most effective prevention is to avoid tubal inflammation or, in cases of preexisting inflammation, to administer effective therapy. Received: December 1998 / Accepted: 25 May 1999     

Ectopic pregnancy and emergency care: ethical and legal issues.

Ectopic or tubal pregnancy presents a medical emergency that requires prompt treatment in order to contain risks of maternal death and morbidity, including loss of future fertility. Medical circumstances involving individual patients and resources of the prevailing health care system will determine the options and means of treatment. Termination of ectopic pregnancy does not constitute or directly implicate abortion. Any practice of deliberately delaying treatment of reliably diagnosed ectopic pregnancy, on non-clinical grounds, until rupture of the fallopian tube has occurred or is imminent, in order to justify termination of the ectopic pregnancy on grounds of saving the patient's life, is unethical and illegal. Those who undertake or counsel deliberate delay of medically-indicated treatment can be charged with criminal offences and civil (non-criminal) liability, and medical professional misconduct. On reliable diagnosis, prompt treatment to remove ectopic pregnancy is legally justified, and ethically and legally required.     

输卵管妊娠患者巨细胞病毒感染分析

目的 探讨输卵管妊娠患者生殖道巨细胞病毒感染情况。方法 应用酶联免疫吸附技术(ELLSA)检测输卵管妊娠患者直清中巨细胞病毒(cytomegalovius, CMV)IgG抗体和特异性IgM抗体,同时应用多聚酶链反应(PCR)检测输卵管妊娠患者宫颈分泌物、宫腔冲洗物以及手术时输卵管妊娠组织标本中CMV DNA。结果 49例输卵管妊娠患者血清IgG抗体阳性21例,阳性率42.86％;宫颈分泌物CMV DNA阳性10例,阳性率20.40％;宫腔冲洗物CMV DNA阳性9例,阳性率18.36％;输卵管妊娠组织CMV DNA阳性4例,阳性率8.16％;其中1例血清IGg抗体阳性并伴有宫颈、宫腔分泌物及输卵管妊娠组织CMV DNA阳性;4例宫颈组织与宫腔组织同时阳性。结论 既往曾有过巨细胞病毒感染者发生输卵管妊娠的风险增加,巨细胞病毒感染,尤其是生殖道巨细胞病毒感染可以导致输卵管妊娠。     

Vaginal length and incidence of dyspareunia after total abdominal versus vaginal hysterectomy

Objective

To evaluate the vaginal length and incidence of dyspareunia after total abdominal hysterectomy compared to vaginal hysterectomy.

Study design

This is a prospective observational study. Sixty-six patients were invited to participate in the study who were already planned to undergo abdominal or vaginal hysterectomy for different benign indications in the OB/GYN department, Sohag University Hospital, during the period from March 2007 till April 2009. Patients were classified into two groups. Thirty-six patients who were planned to undergo total abdominal hysterectomy (TAH) represented the first group, and 30 patients who were planned to undergo vaginal hysterectomy (VH) represented the second group. Vaginal length was obtained just before the operation and three times postoperatively. Pre- and post-operative dyspareunia was reported.

Results

The mean pre-operative and post-operative vaginal lengths in the TAH group were nearly the same (10.5 ± 2.1 cm vs. 10.2 ± 1.8 cm) without statistically significant difference. In the VH group, there was a statistically significant difference between pre- and post-operative vaginal length (10.1 ± 1.9 cm vs. 8.4 ± 1.6 cm). In the TAH group, 2 patients (5%) reported a newly developed post-operative dyspareunia. In VH group, 6 patients (20%) developed dyspareunia after surgery.

Conclusion

Postoperative dyspareunia is more common after vaginal hysterectomy compared to abdominal hysterectomy. This may be attributed to postoperative shortening of the vagina secondary to excessive trimming of the vaginal walls especially if VH was done for utero-vaginal prolapse.     

Optimal time interval between laparoscopic tubal ligation for hydrosalpinges and ICSI-ET

ObjectiveTo determine the optimal time interval between performing laparoscopic tubal ligation for hydrosalpinges and an ICSI-ET treatment cycle.DesignA retrospective cohort study.SettingPrivate infertility clinic.Patient(s)The study group included 69 infertile women who had laparoscopic tubal ligation for hydrosalpinges. 41 patients (group A) had an ICSI-ET cycle <10 weeks after laparoscopic tubal surgery, 20 patients (group B) had an ICSI-ET cycle 10 and 16 weeks after surgery, and 20 patients (group C) had an ICSI-ET cycle >16 weeks after surgery.Intervention(s)laparoscopic tubal ligation and ICSI-ET.Main outcome measure(s)Pregnancy rate, clinical pregnancy rate and implantation rate.Result(s)Pregnancy rates were 39%, 50% and 50%, clinical pregnancy rates 31.7%, 45% and 50%, and implantation rates 14.8%, 21.5% and 18% for groups A, B and C respectively.Conclusion(s)Although the reduction in pregnancy rate, clinical pregnancy rate and implantation rate in Group A, as compared Groups B and C, did not reach statistical significance, our results suggest that ICSI-ET treatment cycles be postponed for at least 10 weeks after laparoscopic tubal ligation for hydrosalpinx. A larger prospectively randomized study should be conducted to confirm the minimum delay period required for endometrial receptivity to recover.     

早期易误诊的宫内妊娠与异位妊娠的鉴别诊断及危险因素探讨

目的　探讨宫内妊娠与异位妊娠的鉴别诊断及异位妊娠的危险因素。方法　 1 998年 1月至 2 0 0 2年7月对 36例疑为异位妊娠的宫内妊娠患者和 72例异位妊娠患者进行分析 ,并用Logistic回归法研究异位妊娠的危险因素。结果　宫内妊娠组阴道流血、腹部压痛、宫颈举痛、附件区压痛发生率明显低于异位妊娠组 (P <0 0 1、P <0 0 5、P <0 0 1、P <0 0 1 ) ,血红蛋白高于异位妊娠组 (P <0 0 5 ) ,B超下附件包块体积小于异位妊娠组 (P <0 0 5 )。阴道流血、宫颈举痛、血 β HCG、B超下附件包块体积是异位妊娠的危险因素 ,子宫压痛不支持异位妊娠。结论　阴道流血、宫颈举痛、血 β HCG、B超下附件包块体积、子宫压痛是宫内妊娠与异位妊娠的鉴别要点。