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Microsurgical Reanastomosis of the Fallopian Tubes for Reversal of Sterilization

1982; Lippincott Williams & Wilkins; Volume: 37; Issue: 2 Linguagem: Inglês

10.1097/00006254-198202000-00024

1533-9866

George M. Grunert, Terrance S. Drake, Norman K. Takaki,

Uterine Myomas and Treatments

There has been a steady increase in the use of tubal sterilization for contraception and a parallel increase in the number of women requesting reversal. Traditional surgical reversal techniques offer a 30 per cent pregnancy rate, whereas gynecological microsurgery appears to improve the pregnancy rate due to the more accurate reapproximation of the tubal lumina. This study presents the surgical technique and pregnancy results of microsurgical reanastomosis at the Naval Regional Medical Center, Oakland, California, and at the National Naval Medical Center, Bethesda, Maryland. From 1976 through 1979, 63 couples at the authors' institutions requests reversal of tubal sterilization. The mean age at sterilization was 24.9 years, and the mean age at request for reversal was 29.7 years. The mean gravidity was 3.7, with a mean of 2.8 living children. Reasons for requesting reversal were a change of relationship in 51 women (80 per cent), death of a child in six (10 per cent), and a desire for more children by the same partner in six (10 per cent). Of the initial group, 23 women were excluded, which left a study population of 40 women who underwent microsurgical reanastomosis. The follow-up period in this group ranged from 6 months to 4 years. Reanastomosis, if indicated, was performed immediately after laparoscopy. The tubes were elevated with moist packs, and the proximal stump was distended with a diluted methylene blue solution injected through an intrauterine Foley catheter. The tube was serially transected until free flow of dye and normal-appearing endosalpinx were identified. The distal stump was treated likewise by means of retrograde chromopertubation. Tissue handling was atraumatic; fingers, glass rods, or delicate microsurgical instruments were used. Hemostasis was obtained by either a unipolar needle-point electrode or microsurgical forceps. Sponging was avoided, and tissues were kept moist at all times with an irrigating solution of 1000 ml of normal saline with 100 mg of hydrocortisone succinate and 1000 units of heparin. Tubal ends were approximated by suturing the meso-salpinx with 6–0 polyglycolic acid suture. No special tubal clamps were used. End to end asastomosis was carried out in two layers, the first approximating the muscularis with either 8–0 polyglycolic acid or monofilament nylon suture on an atraumatic microsurgical needle. An attempt was made not to include the endosalpinx in the sutures. The serosa and remaining meso-salpinx were closed with interrupted sutures of 6–0 polyglycolic, care being taken not to distort the anastomosis line. Chromopertubation was performed to ensure patency, but no attempt was made to obtain a water-tight anastomosis line. The sterilization methods most favorable for reversal appear to be those with the least amount of tubal destruction, e.g., the Pomeroy and tubal ring types. Multiple coagulation techniques have the worst prospect for reversal. No patients sterilized by tubal clips were encountered. Of the 40 women who underwent reversal, three did not attempt pregnancy. There have been 26 pregnancies in 22 of the 37 women trying to conceive (59 per cent). There was a trend toward higher pregnancy rates with ampullary-isthmic anastomosis, but this did not reach statistical significance. The mean interval from surgery to conception in those women who became pregnant was 8.4 months. One ectopic pregnancy occurred in a woman whose contra-lateral tube appeared to be patent at later hysterosalpin-gography. There were two operative complications: a superficial wound infection that responded to local treatment and an incidental cystotomy that was repaired successfully.