Family planning is a major concern for many young couples. Contraception (temporary prevention of pregnancy) and sterilization (permanent prevention of pregnancy) are two available options. Sterilization (female and male) is one of the most popular techniques chosen by couples (USA) planning their families.
A number of couples that have undergone (permanent) sterilization procedures eventually find themselves in the position of desiring further children. Unfortunately, reversal of these (permanent) surgical techniques is not always possible (regardless of the surgical talent and experience of the operating surgeon).
Following tubal reanastomosis (reversal) the outcome of surgery can be measured either in terms of tubal patency (a large percentage of the tubes remain open) or restored fertility (not all open tubes will function properly). Additionally, the chances for a tubal (ectopic) pregnancy are increased (up to 25% of pregnancies) after tubal surgery.
Tubal sterilization can be performed using a number of different techniques, each with differing ability to be reversed at a later time. The common procedures include
(1) modified Pomeroy procedure
This procedure is often performed for postpartum tubal ligations. A small knuckle of the midportion of the fallopian tube is grasped with an atraumatic clamp, the base of the elevated loop is ligated with absorbable suture, and the portion of the ligated knuckle of tube (usually 1-3 cm) is cut and removed. This technique does not use cautery so that reversal depends predominantly on the amount of tube removed (varies).
(2) bipolar coagulation via laparoscopy
A common method of laparoscopic tubal ligation is bipolar cautery, which involves grasping (several different) portions of the fallopian tube within the jaws of the bipolar instrument, applying current between the jaws of the instrument (lateral thermal damage is usually less than 2-3 cm, which is less than that seen with monopolar cautery), and completely desiccating the inner lining (endosalpinx) of the tube in the area of the burn. The success of a reversal procedure after bipolar cautery depends on the amount of tube destroyed by the ligation procedure.
(3) application of silicone bands
A common method of laparoscopic tubal ligation involves application of a small silicone rubber band (fallope ring) over a knuckle of the fallopian tube. With this technique, an applicator is entered laparoscopically, grasping tongs can be extended from the tip of the applicator and placed around a portion of the fallopian tube, the grasped portion of the fallopian tube is retracted into the applicator device so as to create a small knuckle of tube, a silicone rubber band is applied to the base of the knuckle, and the rubber band essentially constricts any blood flow to the knuckle of tube so that this portion of the (devascularized) tube eventually becomes necrotic and falls off. This procedure results in only a small area of tubal damage so reversal is generally fairly successful.
(4) less common techniques
Spring (Hulka) clips can be applied (perpendicularly) across a section of the fallopian tube in the midportion with compression of only a small area of tube (less than .5cm) to essentially occlude the tube. With this method there is minimal damage to surrounding tissue and subsequent tubal reanastomosis has a high success rate (in terms of both patency and fertility).
Fimbriectomy is the removal of the distant portion (fimbria) of the fallopian tube, which results in the tube becoming incapable of “picking up “ mature eggs from the ovaries. The fimbriae are removed during this procedure so that a new fimbria (neosalpingostomy) must be performed to try to restore fertility. These reconstruction procedures are rarely successful.
The Irving and Uchida methods of tubal ligation involve removal of a knuckle of fallopian tube and then embedding the end(s) of the cut fallopian tube below the serosa (peritoneal) surface of the uterus (Irving) or mesosalpinx (Uchida) in an attempt to limit subsequent fistula formation. These methods are often difficult to reverse.