Tubal reversal
Encyclopedia
Tubal reversal, also called tubal sterilization reversal or tubal ligation reversal, is a surgical procedure that attempts to restore fertility
to women after a tubal ligation
. By rejoining the separated segments of fallopian tube
, tubal reversal may give women the chance to become pregnant again.
is a muscular organ extending from the uterus
and ending next to the ovary
. The tube is attached to the ovary by a small ligament. The inner tubal lining is rich in cilia. These are microscopic hair-like projections that beat in waves that help move the egg or ovum
to the uterus in conjunction with muscular contractions of the tube.The fallopian tube is normally about 10 cm (4 inches) long and consists of several segments. Starting from the uterus and proceeding outward, these are the:
to open and reconnect the fallopian tube segments that remain after a tubal sterilization.
, there are usually two remaining fallopian tube segments - the proximal tubal segment that emerges from the uterus
and the distal tubal segment that ends with the fimbria
next to the ovary
. After opening the blocked ends of the remaining tubal segments, a narrow flexible stent
is gently threaded through their inner cavities or lumens and into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes (mesosalpinx
). The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscular portion (muscularis externa
) and outer layer (serosa), while avoiding the inner layer (mucosa) of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.
), using small, specially-designed instruments to repair and reconnect the fallopian tubes.
After general anesthesia has been administered, a 10mm (less than ½-inch) tube (trocar
) is inserted just at the lower edge of the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The laparoscope (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The fallopian tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than ¼-inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.
Once the connection (anastomosis
) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well.
Patients are seen between 5–7 days after the operation to look at the small incisions and remove any stitches if necessary. Most of the time, the few stitches that were placed will be under the skin and will be absorbed by the body, without need for removal.
Patients should wait two to three months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of ectopic pregnancy
(pregnancy inside the fallopian tube instead of in the uterus).
When performed by a trained laparoscopic tubal reversal surgeon, laparoscopic tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery – namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars.
The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.
Robotic surgery experts have suggested robotic tubal ligation reversal offers the advantage of smaller incisions when compared to traditional laparotomy tubal reversal surgery. These smaller incisions have been reported to result in less pain and quicker return to work after robotic tubal reversal when compared to traditional tubal ligation reversal using larger abdominal incisions. Robotic experts have also suggested the robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal. The potential disadvantages to robotic surgery are longer operating times and higher costs.
A retrospective, Cleveland Clinic study compared 26 patients who underwent robotic assisted tubal reversal to 41 patients who underwent outpatient mini-laparotomy (abdominal incision) tubal reversal. Robotic tubal reversal patients, when compared to abdominal tubal reversal surgery patients, had longer times under anesthesia (283 minutes vs 205 minutes) and longer times in surgery (229 minutes vs 181 minutes). On average, robotic tubal reversal patients returned to work one week sooner than abdominal tubal reversal patients and the robotic tubal reversal surgeries were also more expensive than abdominal tubal reversal surgeries.
An Ohio State University study evaluating robotic tubal reversal vs abdominal tubal reversal discovered similar findings but also evaluated pregnancy outcomes. Robotic tubal reversal surgery, when compared to abdominal tubal reversal surgery, had longer operative times (201 minutes vs 155 minutes), shorter hospital stays (4 hours compared to 34 hours), and quicker return to activities of daily living. Pregnancy outcomes of robotic tubal reversal surgery patients were also compared to pregnancy outcome of abdominal incision tubal reversal patients. Approximately 65% of the robotic tubal reversal surgery patients became pregnant compared with 50% of the abdominal incision patients. Of the pregnancies, 6 abnormal pregnancies were in the robotic tubal reversal patients (4 ectopic and 2 miscarriage) and 2 were in the abdominal incision patients (1 ectopic and 1 miscarriage). Both surgeries were expensive and were found to cost in excess of $92,000. Robotic tubal reversal surgery was slightly more costly than the abdominal incision tubal reversal.
is a tubal occlusion procedure that was approved by the FDA in 2002. The Essure procedure involves inserting a small camera (hysteroscope) through the cervix
and into the uterine cavity. Two small, metallic coils are then inserted into each tubal ostia and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to be blocked with scar tissue. To confirm tubal closure, a hysterosalpingogram should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure can be repeated or another type of tubal occlusion method can be performed.
Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed by tubouterine implantation as described above.
Reversal of Adiana is similar to reversal of Essure sterilization.
Fertility
Fertility is the natural capability of producing offsprings. As a measure, "fertility rate" is the number of children born per couple, person or population. Fertility differs from fecundity, which is defined as the potential for reproduction...
to women after a tubal ligation
Tubal ligation
Tubal ligation or tubectomy is a surgical procedure for sterilization in which a woman's fallopian tubes are clamped and blocked, or severed and sealed, either method of which prevents eggs from reaching the uterus for fertilization...
. By rejoining the separated segments of fallopian tube
Fallopian tube
The Fallopian tubes, also known as oviducts, uterine tubes, and salpinges are two very fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into the uterus, via the utero-tubal junction...
, tubal reversal may give women the chance to become pregnant again.
Tubal anatomy
The fallopian tubeFallopian tube
The Fallopian tubes, also known as oviducts, uterine tubes, and salpinges are two very fine tubes lined with ciliated epithelia, leading from the ovaries of female mammals into the uterus, via the utero-tubal junction...
is a muscular organ extending from the uterus
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
and ending next to the ovary
Ovary
The ovary is an ovum-producing reproductive organ, often found in pairs as part of the vertebrate female reproductive system. Ovaries in anatomically female individuals are analogous to testes in anatomically male individuals, in that they are both gonads and endocrine glands.-Human anatomy:Ovaries...
. The tube is attached to the ovary by a small ligament. The inner tubal lining is rich in cilia. These are microscopic hair-like projections that beat in waves that help move the egg or ovum
Ovum
An ovum is a haploid female reproductive cell or gamete. Both animals and embryophytes have ova. The term ovule is used for the young ovum of an animal, as well as the plant structure that carries the female gametophyte and egg cell and develops into a seed after fertilization...
to the uterus in conjunction with muscular contractions of the tube.The fallopian tube is normally about 10 cm (4 inches) long and consists of several segments. Starting from the uterus and proceeding outward, these are the:
- Interstitial segment - extends from the uterine cavity through the uterine muscle
- Isthmic segment - narrow muscular portion adjacent to the uterus
- Ampullary segment - wider and longer middle part of the tube
- Infundibular segment - funnel shaped segment next to the fimbrial end
- Fimbrial segment - wide opening at the end of the tube facing the ovary
Tubal reversal surgeries
Tubal reversal surgeries utilize the techniques of microsurgeryMicrosurgery
Microsurgery is a general term for surgery requiring an operating microscope. The most obvious developments have been procedures developed to allow anastomosis of successively smaller blood vessels and nerves which have allowed transfer of tissue from one part of the body to another and...
to open and reconnect the fallopian tube segments that remain after a tubal sterilization.
Tubotubal anastomosis
Following a tubal ligationTubal ligation
Tubal ligation or tubectomy is a surgical procedure for sterilization in which a woman's fallopian tubes are clamped and blocked, or severed and sealed, either method of which prevents eggs from reaching the uterus for fertilization...
, there are usually two remaining fallopian tube segments - the proximal tubal segment that emerges from the uterus
Uterus
The uterus or womb is a major female hormone-responsive reproductive sex organ of most mammals including humans. One end, the cervix, opens into the vagina, while the other is connected to one or both fallopian tubes, depending on the species...
and the distal tubal segment that ends with the fimbria
Fimbria
A fimbria is a Latin word that literally means "fringe." It is commonly used in science and medicine, with its meaning depending on the field of study or the context...
next to the ovary
Ovary
The ovary is an ovum-producing reproductive organ, often found in pairs as part of the vertebrate female reproductive system. Ovaries in anatomically female individuals are analogous to testes in anatomically male individuals, in that they are both gonads and endocrine glands.-Human anatomy:Ovaries...
. After opening the blocked ends of the remaining tubal segments, a narrow flexible stent
Stent
In the technical vocabulary of medicine, a stent is an artificial 'tube' inserted into a natural passage/conduit in the body to prevent, or counteract, a disease-induced, localized flow constriction. The term may also refer to a tube used to temporarily hold such a natural conduit open to allow...
is gently threaded through their inner cavities or lumens and into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes (mesosalpinx
Mesosalpinx
The mesosalpinx is part of the lining of the abdominal cavity in higher vertebrates, specifically the portion of the broad ligament that stretches from the ovary to the level of the uterine tube....
). The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscular portion (muscularis externa
Muscularis externa
The muscular coat is a region of muscle in many organs in the vertebrate body, adjacent to the submucosa membrane...
) and outer layer (serosa), while avoiding the inner layer (mucosa) of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.
Tubouterine implantation
In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal segment. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubouterine implantation.Ampullary salpingostomy
Fimbriectomy is an uncommon type of tubal ligation that is performed by removing the fimbrial portion of the fallopian tube next to the ovary, leaving the tubal segment attached to the uterus. After fimbriectomy, the remaining tubal segment can be opened by the technique ampullary salpingostomy. A microsurgical electrode is used to open the tubal end and expose the internal lining. When the opening has been enlarged sufficiently and the internal lining or endothelium has extruded from the tubal end, sutures are placed to keep the endothelium folded outward over the edge and to prevent the tube from closing again.Mini-laparotomy tubal reversal
Mini-laparotomy for tubal reversal surgery involves making a small incision in the abdominal wall just above the pubic bone after shaving the hair with a sterile hair clipper. The size and location of the incision as well as the plastic surgery techniques used to close it make the hair-line scar invisible when it has healed. Atraumatic surgical techniques involve the use of local anesthesia at the incision site and other tissues operated upon. This makes the surgery comfortable and minimizes post-operative pain. As opposed to standard operative methods, avoiding the use of surgical retractors and packs, constantly irrigating tissues to keep them moist and at body temperature, and operating under magnification throughout the procedure results in very rapid patient recovery. Operating with microsurgical instruments allows precision in suturing of the tubal segments.Laparoscopic tubal reversal
Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure (laparoscopyLaparoscopy
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions with the aid of a camera...
), using small, specially-designed instruments to repair and reconnect the fallopian tubes.
After general anesthesia has been administered, a 10mm (less than ½-inch) tube (trocar
Trocar
A trocar is a medical instrument with a sharply pointed end, often three-sided, that is used inside a hollow cylinder to introduce this into blood vessels or body cavities...
) is inserted just at the lower edge of the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The laparoscope (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The fallopian tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than ¼-inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.
Once the connection (anastomosis
Anastomosis
An anastomosis is the reconnection of two streams that previously branched out, such as blood vessels or leaf veins. The term is used in medicine, biology, mycology and geology....
) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well.
Patients are seen between 5–7 days after the operation to look at the small incisions and remove any stitches if necessary. Most of the time, the few stitches that were placed will be under the skin and will be absorbed by the body, without need for removal.
Patients should wait two to three months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of ectopic pregnancy
Ectopic pregnancy
An ectopic pregnancy, or eccysis , is a complication of pregnancy in which the embryo implants outside the uterine cavity. With rare exceptions, ectopic pregnancies are not viable. Furthermore, they are dangerous for the parent, since internal haemorrhage is a life threatening complication...
(pregnancy inside the fallopian tube instead of in the uterus).
When performed by a trained laparoscopic tubal reversal surgeon, laparoscopic tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery – namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars.
Robotic assisted tubal reversal
Robotic assisted tubal reversal surgery is a surgical procedure in which the fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system.The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.
Robotic surgery experts have suggested robotic tubal ligation reversal offers the advantage of smaller incisions when compared to traditional laparotomy tubal reversal surgery. These smaller incisions have been reported to result in less pain and quicker return to work after robotic tubal reversal when compared to traditional tubal ligation reversal using larger abdominal incisions. Robotic experts have also suggested the robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal. The potential disadvantages to robotic surgery are longer operating times and higher costs.
A retrospective, Cleveland Clinic study compared 26 patients who underwent robotic assisted tubal reversal to 41 patients who underwent outpatient mini-laparotomy (abdominal incision) tubal reversal. Robotic tubal reversal patients, when compared to abdominal tubal reversal surgery patients, had longer times under anesthesia (283 minutes vs 205 minutes) and longer times in surgery (229 minutes vs 181 minutes). On average, robotic tubal reversal patients returned to work one week sooner than abdominal tubal reversal patients and the robotic tubal reversal surgeries were also more expensive than abdominal tubal reversal surgeries.
An Ohio State University study evaluating robotic tubal reversal vs abdominal tubal reversal discovered similar findings but also evaluated pregnancy outcomes. Robotic tubal reversal surgery, when compared to abdominal tubal reversal surgery, had longer operative times (201 minutes vs 155 minutes), shorter hospital stays (4 hours compared to 34 hours), and quicker return to activities of daily living. Pregnancy outcomes of robotic tubal reversal surgery patients were also compared to pregnancy outcome of abdominal incision tubal reversal patients. Approximately 65% of the robotic tubal reversal surgery patients became pregnant compared with 50% of the abdominal incision patients. Of the pregnancies, 6 abnormal pregnancies were in the robotic tubal reversal patients (4 ectopic and 2 miscarriage) and 2 were in the abdominal incision patients (1 ectopic and 1 miscarriage). Both surgeries were expensive and were found to cost in excess of $92,000. Robotic tubal reversal surgery was slightly more costly than the abdominal incision tubal reversal.
Essure sterilization reversal
Essure sterilizationEssure
Essure is a permanent transcervical sterilization procedure for women developed by Conceptus Inc. It was approved for use in the United States on November 4, 2002....
is a tubal occlusion procedure that was approved by the FDA in 2002. The Essure procedure involves inserting a small camera (hysteroscope) through the cervix
Cervix
The cervix is the lower, narrow portion of the uterus where it joins with the top end of the vagina. It is cylindrical or conical in shape and protrudes through the upper anterior vaginal wall...
and into the uterine cavity. Two small, metallic coils are then inserted into each tubal ostia and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to be blocked with scar tissue. To confirm tubal closure, a hysterosalpingogram should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure can be repeated or another type of tubal occlusion method can be performed.
Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed by tubouterine implantation as described above.
Adiana sterilization reversal
Adiana sterilization was approved by the FDA in 2009. Adiana sterilization is a hysteroscopic tubal occlusion procedure, which is very similar to Essure sterilization. The Adiana procedure involves inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. A smaller catheter is inserted into the tubal ostia. The catheter emits radiowaves (microwaves). The radiowaves cause injury to the tubal lining and will result in the tube gradually closing. Prior to removal of the catheter a small silicone stent is left inside the isthmic portion of the tube and this promotes tubal closure by the acceleration of the tubal scarring.Reversal of Adiana is similar to reversal of Essure sterilization.