Hysterosalpingographic follow-up of laparoscopic sterilization.

Two hundred and fifty of 323 laparoscopically sterilized patients had hysterosalpingographic (HSG) follow-up. A Foley catheter was used in hysterosalpingography. Of these patients, 3.6 per cent demonstrated fistula; 1.2 per cent were found to have round ligament burns, and 0.618 per cent became pregnant. Mechanism of fistula formation, prevention, and management is discussed. The incidence of intrauterine pregnancy and ectopic pregnancy after laparoscopic sterilization is discussed, and the literature is reviewed. Based on these data, it is concluded that HSG follow-up is helpful in teaching institutions and where the laparoscopic sterilization is carried out by inexperienced operators. Routine HSG follow-up is not recommended.     

Silicone band sterilization with radiographic and laparoscopic evaluation.

Laparoscopic tubal sterilization, using a Silastic band to occlude the tubal lumen, was performed on 224 patients. The incidence of complications was low and only 2 pregnancies occurred. Further evaluation by hysterosalpingography on 97 patients revealed 2 distinct images. The site of tubal occlusion was seen on laparoscopy performed on 7 patients. The radiographic and laparoscopic findings are discussed.     

Bipolar cautery for laparoscopic sterilization.

Laparoscopic sterilization with a bipolar electrode was performed in 62 patients. The sterilization failed in one patient and was questionable in another. The effectiveness was assessed by hysterosalpingography (HSG) in 51 patients. No complications due to laparoscopy occurred. The method is considered to be advantageous because of the low risk of complications. The effectiveness of the method seems to be acceptable.     

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.     

A summary of reported pregnancies after hysteroscopic sterilization

The purpose of this article is to describe 64 unintended pregnancies reported by patients who had undergone hysteroscopic sterilization and to provide recommendations for avoiding post-procedure pregnancies. Sixty-four pregnancies out of an estimated 50,000 procedures were reported to the device manufacturer from 1997 through December 2005. Most occurred in patients without appropriate follow-up. Other causes included misread hysterosalpingograms, undetected preprocedure pregnancies, and failure to follow product-labeling guidelines. The risk of pregnancy with hysteroscopic sterilization may be reduced by educating patients about the necessity of follow-up, ensuring that patients use effective contraception before and after placement, following the instructions for use, and adhering to the hysterosalpingography protocol.     

Outpatient microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy.

A prospective study of 17 cases of microsurgical reversal of tubal sterilization by a combined approach of laparoscopy and minilaparotomy was performed. Inclusion criteria included age less than 43; weight less than ideal body weight plus 20%; documentation of ovulation; 2 cm of proximal oviduct on hysterosalpingography; and a normal semen analysis or postcoital test. A comparison group of the 5 cases of sterilization reversal performed by a standard inpatient technique during the same period was analyzed. The study technique was performed on an outpatient basis in 15 of the 17 cases, 12 patients (71%) conceived 13 intrauterine pregnancies, one ectopic pregnancy occurred, and total patient costs and time until return to work were significantly less with the study versus standard technique.     

The diagnosis of tubointestinal and tubovesical fistulas by hysterosalpingography

Four cases of tubointestinal fistulas and one case of tubovesical fistula diagnosed by hysterosalpingography are presented and the characteristic x-ray findings of tubal fistula are described.The tuberculous origin of the fistulas is suspected in most of these cases but was confirmed by histological examination in only one case and suggested by the roentgenograms in two other cases.     

Results of reversal of sterilization performed in Danish women 1978-1983

To follow up the outcome of refertilization after female sterilization, the Danish women refertilized from 1978 through 1983 were contacted by questionnaires, and the operative reports from sterilization and refertilization were obtained. Ninety percent (132/147) responded. The median follow up time was 39 months (range 18-83). Forty-four percent of the women became pregnant, 26% gave live birth, 7% had a miscarriage only, and 11% had a tubal pregnancy. The results of reversal of sterilization by means of conventional surgery (n = 101) and microsurgery with microscope or magnifying glasses (n = 31) did not differ in terms of number of live births. Refertilization after sterilization by laparoscopic methods was more successful: 34% of these women gave live birth, whereas 19% gave live birth after reversal of sterilization performed by resection of the tubes. The predictive value of peroperative tubal patency for subsequent pregnancy was 32%, whereas the prediction of no pregnancy in cases of no patency was found to be 60% correct. Postoperative hysterosalpingography (HSG) showing tubal patency was of predictive value for later pregnancy in 45%, whereas no patency by HSG gave a correct prediction for no pregnancy in 94% of the cases. In order to improve the skill of the surgeons, and thus, apply the microsurgical technique to full advantage, it would seem necessary to concentrate reversal of female sterilization on a small number of departments especially interested in this technique.     

Prospective analysis of office-based hysteroscopic sterilization

STUDY OBJECTIVES: To evaluate the efficacy of performing the Essure hysteroscopic sterilization in an office-based setting. DESIGN: Prospective, longitudinal analysis (Canadian Task Force classification II-3). SETTING: University out-patient office. PATIENTS: All patients undergoing permanent sterilization in our outpatient office who opted for hysteroscopic sterilization were included. INTERVENTIONS: Hysteroscopic placement of the Essure device in an office-based setting with only non-steroidal antiinflammatory drugs and paracervical block. MEASUREMENTS AND MAIN RESULTS: Multiple data points were collected on each patient including demographic data, specific procedural information, and 12-week hysterosalpingogram data. Most of our patients were Hispanic and had an average body mass index of 30.3. Average time to perform the procedure was 12.4 minutes, with the steepest improvement in the first 13 cases. Bilateral placement of the device was successful in 98 (96%) of 102 patients. Of these patients 92 have 12-week hysterosalpingography results (6 patients were lost to follow-up), with 90 (98%) showing bilateral tubal occlusion. There were no intraprocedural or postprocedural complications. CONCLUSION: In our institution and in our experience, office-hysteroscopic placement of the Essure device is a feasible and effective approach for permanent sterilization.     

Jejunouterine fistula: a case report

Jejunouterine fistula is a rare type of fistulous communication between the small intestine and the genital tract. This fistula may result from pelvic tumours, obstetric or surgical intervention and inflammatory disease. Cross-sectional imaging modalities, including ultrasonography, magnetic resonance imaging (MRI) and computed tomography (CT), are useful investigations which may demonstrate the site and track of the fistula. Traditional contrast investigations, including hysterosalpingography, are also helpful. Surgical resection of the fistula with primary anastomosis is curative in the majority of cases.     

Laparoscopic repair of a uterine fistula

We report a case of fistula between the uterus and broad ligament in a 28-year-old woman after cesarean section. The patient presented with right-sided pelvic pain, which worsened during menstruation. The diagnosis was made at laparoscopy. The patient subsequently underwent successful laparoscopic repair of the fistula confirmed by hysterosalpingography 4 months after surgery.     

Outcomes in the Ultrasound Follow-up of the Essure Micro-Insert: Complications and Proper Placement

ObjectiveTo review the use of three-dimensional ultrasound follow-up of the Essure micro-insert placement at three months for the identification of misplaced coils and complications.MethodsWe conducted a retrospective cohort study of reproductive age women requesting permanent sterilization in a tertiary care ambulatory women's clinic. Women who underwent placement of the Essure micro-insert were assessed for appropriate positioning of the Essure micro-insert coil using threedimensional ultrasound as well as hysterosalpingography when indicated.ResultsA total of 610 women who had undergone the Essure procedure with ultrasound follow-up at three months were retrospectively reviewed and in 524 (86%) the location and shape were both normal. The remaining 86 (15%) required hysterosalpingography to confirm proper placement, 34 because of a non-diagnostic ultrasound and the remaining 52 for a complication noted on ultrasound, including perforation, proximal or distal migration of the device, or device expulsion.ConclusionUltrasound can be used at three months after Essure placement to identify normal placement as well as misplaced and perforated devices     

Laparoscopic sterilization with the Falope-ring technique in the puerperium

One hundred and forty-one women were planned to be sterilized by the Falope-ring technique after vaginal term delivery. Two pregnancies (1.55%) occurred during an average observation period of 43.2 months. Tearing of the mesosalpinx with bleeding requiring laparotomy occurred in 2 cases, and was the major operative complication seen. In 3 cases, laparotomy was performed because of reduced visual field caused by the enlarged uterus and in 2 cases because of technical problems with maintaining pneumoperitoneum. In 10 patients, hysterosalpingography was performed. In 2 cases leakage was demonstrated and these patients were readmitted to laparoscopic sterilization in the interval phase. One woman was admitted to the hospital with acute lower abdominal pain one year after sterilization; laparotomy showed the salpinx to be twisted three times around the ring. The Falope-ring technique is recommended as a safe, easy and quick method for sterilization in the puerperium.     

Estimated prevalence of müllerian anomalies

Among 167 women who underwent laparoscopic sterilization in the course of one year, 1.2% were found to have a bicornuate uterus. Of them, 111 were offered follow-up by hysterosalpingography (HSG), and the history of their menstrual pattern as well as reproductive potential was recorded. Evaluation of the HSG exposures revealed 3.6% moderately to severely septate uteri (H/L greater than 0.20), and a total of 15.3% had fundal anomalies (H/L greater than 0.10). In women who had always had normal fertility and menstrual cycles of less than 35 days, the corresponding frequencies of septate uterus were 1.2% and 11.8% respectively. Among women who had had oligomenorrheic periods exceeding one year in duration, the frequency of müllerian anomalies was significantly higher (21.1% at H/L greater than 0.20 and 36.8% at H/L greater than 0.10) than in the above-mentioned groups. A control group of infertile oligomenorrheic women revealed that the material was comparable with previously published populations as regard the occurrence of minor müllerian anomalies. It is concluded that the HSG-diagnosed prevalence of developmental uterine anomalies is in general somewhat higher than usually assumed.     

The diagnostic value of hysterosalpingography and hysteroscopy in infertility investigation

Four hundred infertile patients had hysterosalpingography and hysteroscopy as part of their infertility workup. A comparison between the findings of these two procedures was carried out to study their diagnostic value in female infertility investigation. It was found that hysterosalpingography was as accurate as hysteroscopy in the diagnosis of normal or abnormal uterine cavities while the nature of the intrauterine filling defects was accurately revealed by hysteroscopy only. It is concluded that hysterosalpingography is an important screening procedure for the diagnosis of normal or abnormal uterine cavities and that hysteroscopy should be reserved only for the confirmation and treatment of intrauterine anomalies discovered by hysterosalpingography. Therefore we look at the two procedures, hysterosalpingography and hysteroscopy, as complementary techniques.     

A comparative study of hysterosalpingography and laparoscopy in the investigation of infertility.

A comparison of hysterosalpingography and laparoscopy was carried out on 79 infertile women. Out of these, 60 had abnormal and 19 had normal hysterosalpingograms. Of the 19 patients with normal X-rays, nine (47%) had abnormal findings during laparoscopy. In 62% of patients with abnormal hysterosalpingograms, laparoscopic findings confirmed the radiological diagnosis, however in 38% the findings differed. Though hysterosalpingography is an important part of infertility evaluation, a final and definite diagnosis requires endoscopic evaluation of the pelvis.     

Hysteroscopic Sterilization Success in Outpatient vs Office Setting Is Not Affected by Patient or Procedural Characteristics

Study ObjectiveTo determine factors associated with hysteroscopic sterilization success and whether it differs between the operating room and office settings.DesignRetrospective cohort analysis (Canadian Task Force classification II-2).SettingMajor university medical center.PatientsSix hundred thirty-eight women who underwent hysteroscopic sterilization between July 1, 2005, and June 30, 2011.Measurements and Main ResultsData collected included age, body mass index, previous office procedures, previous cesarean section, and presence of myomas or retroverted uterus. Place of surgery, experience of surgeon, insurance type, bilateral device placement, compliance with hysterosalpingography, and confirmation of occlusion were also recorded. Bivariate analysis of patient characteristics between groups was performed using χ² and independent t tests, and identified confounders and associated variables. Multivariate analysis was performed using logistic regression to assess for association and to adjust for confounders. Procedures were performed in the operating room (57%) or in the office (43%). There was no association between success in bilateral device placement or occlusion and any patient characteristic, regardless of surgery setting. Private insurance, patient age, and performance of procedures in the office setting were positively associated with likelihood of compliance with hysterosalpingography.ConclusionSuccessful device placement and tubal occlusion are independent of patient age, body mass index, or setting of the procedure. Association between insurance type and completing hysterosalpingography illustrates an important public health problem. Patients who fail to undergo hysterosalpingography to confirm tubal occlusion may unknowingly be at risk of pregnancy and increased risk of ectopic pregnancy.     

Laparoscopic sterilization with the Falope-ring technique

One hundred and sixteen women were admitted to hospital for laparoscopic sterilization by the Falope-ring technique. Up to the present, and with an average observation period of 20.8 months, no pregnancies have occurred. Bleeding from the distal site of puncture and tubal transection were the most common peroperative complications, occurring in 4.4 and 3.5% respectively. In 80 patients, hysterosalpingography was performed after 3 months as a control. Unilateral leakage was demonstrated in 6 patients; 5 of these were resterilized via a minilaparotomy. The Falope-ring technique is easy and quick to carry out and, when performed correctly, is encumbered with a low rate of complications and failures. The method is recommended as an alternative to sterilization via electrocautery of the tubes.     

Outpatient laparoscopic tubal anastomosis and subsequent fertility.

OBJECTIVE: To determine the reproductive outcome of women who undergo laparoscopic tubal anastomosis. DESIGN: Observational prospective study. SETTING: University-affiliated infertility medical center. PATIENT(S): One hundred two patients seeking reversal of tubal sterilization. INTERVENTION(S): Laparoscopic tubal anastomosis was performed with a one-suture technique. MAIN OUTCOME MEASURE(s): Pregnancy rate. RESULT(S): There were 69 isthmic-isthmic, 16 isthmic-ampullary, 12 cornual-isthmic, and 5 ampullary-ampullary anastomoses. The mean operative time was 71.35 minutes. Eight patients had bilateral tubal obstruction on postoperative hysterosalpingography. Sixty-nine patients (70%) conceived. Sixty-four (65.3%) had ongoing intrauterine pregnancies, 15 (21.7%) had spontaneous abortions, and 5 (7.2%) had ectopic pregnancies. CONCLUSION(S): This study demonstrates that laparoscopic tubal anastomosis can be done safely and successfully on an outpatient basis, reducing costs and postoperative morbidity while accelerating the patient's return to normal activities.     

Sterilization failures with bipolar tubal cautery

From a consecutive series of 105 patients undergoing bipolar tubal sterilization (BPS), ten pregnancies were reported, and a tubal patency rate of 16% was found at hysterosalpingography. There were no significant clinical variables separating the BPS failure patients from those with successful sterilization. Ninety percent of the BPS failures were intrauterine, and 90% occurred within three cycles of BPS. The results of this investigation suggest that (1) BPS tubal occlusion may be associated with an increased failure (pregnancy and tubal patency) rate; (2) the majority of BPS failures are intrauterine gestations; (3) delayed fibrosis, rather than immediate tubal destruction, may be the mechanism of BPS tubal occlusion; (4) for maximum effectiveness, patients undergoing BPS should use alternative contraception for two to three cycles; and (5) surgeons employing BPS require precise training in the application of this modality of female sterilization.