RESEARCH ARTICLE


https://doi.org/10.5005/jp-journals-10006-1796
Journal of South Asian Federation of Obstetrics and Gynaecology
Volume 12 | Issue 4 | Year 2020

Determinants in Outcome of Tubal Recanalization: A Prospective Cohort Study


Laxmi S Sangolli1, Aruna Biradar2, Sangamesh S Mathapathi3, Shreedevi S Kori4, Some Gowda5, Neelamma G Patil6, Rajasri G Yaliwal7, BS Gamini8

1–4,6–8Department of Obstetrics and Gynaecology, BLDE (Deemed to be University) Shri BM Patil Medical College Hospital and Research Centre, Vijayapura, Bijapur, Karnataka, India
5Department of Obstetrics and Gynaecology, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Corresponding Author: Aruna Biradar, Department of Obstetrics and Gynaecology, BLDE (Deemed to be University) Shri BM Patil Medical College Hospital and Research Centre, Vijayapura, Bijapur, Karnataka, India, Phone: +91 8197191472, e-mail: aruna.biradar@yahoo.com

How to cite this article Sangolli LS, Biradar A, Mathapathi SS, et al. Determinants in Outcome of Tubal Recanalization: A Prospective Cohort Study. J South Asian Feder Obst Gynae 2020;12(4):239–242.

Source of support: Nil

Conflict of interest: None

ABSTRACT

Introduction: Tubal sterilization is the most prevalent family planning method practiced in our country. According to National Family Health Survey (NFHS 4) (2015–2016), a total of 51.8% of married women use any method of family planning, of which female sterilization accounts for majority with 48.6%, use of intrauterine device (IUD) by just 0.8% of women, pills by 0.4% of women, and condom by 1.3% women.1 More than 45.5% women undergoing sterilization belong to young reproductive-age group of 20–25 years.2 The gold standard for recanalization has been microsurgical tubal recanalization through laparotomy. Laparoscopy can be used as an alternative route but requires high expertise.3 Although an option of in vitro fertilization is widely available, due to economic constraints people go for microsurgical tubal recanalization as a first option.2

Material and methods: The study involves all women coming to the Department of Obstetrics and Gynecology, Bangalore Medical Collage and Research Institute, Bengaluru, for reversal of sterilization between August 2010 and September 2012.

Results: A total of 40 prospective cases were studied and followed up for at least 1 year of which intrauterine pregnancy was noted in 21 (52.5%) cases, 1 (4.7%) patient had ectopic pregnancy, and 2 (9.5%) had abortions.

Conclusion: The study concluded that factors favoring successful tubal recanalization are age of the patient less than 30 years, interval between sterilization and its reversal less than 4 years, site of anastomosis being isthmo-isthmic, remaining tubal length being more than 6 cm, and when type of previous sterilization was by laparoscopic method.

Keywords: Fertility, Microsurgery, Pregnancy, Sterilization, Tubal length, Tubal recanalization..

INTRODUCTION

Tubal sterilization is the most prevalent family planning method practiced in India. According to National Family Health Survey (NFHS 4) (2015–2016), a total of 51.8% of married women use any method of family planning, of which female sterilization accounts for a majority by 48.6%, intrauterine device (IUD) by just 0.8% of women, pills by 0.4%, and condom by 1.3% women.1 More than 45.5% women undergoing sterilization belong to young reproductive-age group of 20–25 years.2 The gold standard for recanalization has been microsurgical tubal recanalization through laparotomy. Laparoscopy can be used as an alternative route but requires high expertise.3 Although an option of in vitro fertilization is widely available, due to economic constraints, people go for microsurgical tubal recanalization as a first option.2

Tubal recanalization is a surgical procedure that attempts to reinstate the fertility in women who have undergone tubectomy. Female sterilization is an important constituent of National Family Planning Program in India. In recent years, an increasing number of couples of lower age and lower parity request for sterilization voluntarily thinking that their family is complete.4 However, due to unforeseen circumstances, 10% of them regret their decision, and about 1 to 3% want to restore their fertility due to various reasons like, loss of male child, loss of only child, desire to have more children, remarriage, and loss of children in natural calamities.5 Hence, the popularity and the success of tubectomy program largely depends upon the success of its reversal.

Several factors such as the age of the women, type of tubectomy done, duration since tubectomy, and technique of recanalization have been considered to influence the outcome of recanalization. The present study was undertaken to study the factors that may be associated with successful outcome following tubal recanalization.

AIMS AND OBJECTIVES

MATERIALS AND METHODS

The present study was carried out in Department of Obstetrics and Gynecology, Bengaluru Medical Collage and Research Institute, Bengaluru, from August 2010 to September 2012. All the patients undergoing recanalization during the study period were included in this study. A total of 40 women seeking reversal of sterilization with age ≤39 years and normal semen parameters of male partner were included in the study, and women with obvious pelvic inflammatory disease, endometriosis, or fibroid as a cause of infertility and with any contraindications to pregnancy or surgery were excluded from the study. The data were collected and analyzed by Chi-square/Fisher Exact test.

A detailed history was elicited, focusing on details of sterilization, including the age at the time of sterilization, parity at the time of sterilization, type of sterilization, interval between sterilization and reversal, and reason for reversal of sterilizations. Menstrual history was recorded. Obstetrics history including parity and the cause for death of child was recorded. A thorough clinical examination was done followed by routine laboratory evaluation, such as complete blood count, random blood sugars, blood grouping and Rh typing, thyroid function test, and serology for HIV and HBsAg. Semen analysis of the husband was done. After obtaining the informed written consent, recanalization was done and were followed up for 1 year.

Tubal recanalization was carried out in the postmenstrual phase. The abdomen was opened with transverse suprapubic incision, and the findings like endometriosis and PID if present were noted. Under magnification with microsurgical instruments and constant irrigation with heparinized ringer lactate solution, tubectomized sites were freshened. Anastomosis was done by means of 6-0 Vicryl suture materials for muscularis. First bite was taken at 6-o-clock position, that is mesenteric border, and later 3-, 9-, 12-o clock position. Serosa was approximated similarly. Patency of both ends was established by direct tube testing by injecting methylene blue dye. For fembriectomy cases, cuff salpingostomy was done. Perfect hemostasis was achieved using bipolar cautery. Tubal length was noted at the end of the surgery. Hydroflotation was done with normal saline.

The parameters studied were condition of the tubes, ovaries, uterus, and type of tubectomy, anatomical site of anastomosis, and final length of the reconstructed tube. Any complications if present were recorded. Women were discharged after suture removal and were advised regarding the fertile period and risk of ectopic pregnancy and not to abstain from sexual activity. Then, they were followed for a period of 1 year, and events like pregnancy, ectopic pregnancy, and pelvic infection were recorded. If there was no conception within 1 year, hysterosalpingogram was done to check for tubal patency.

Intraoperative Photographs (Figs 1 to 4)

Fig. 1: Type and site of sterilization

Fig. 2: Tubectomised sites being freshened

Fig. 3: Isthmo-isthmic anastomosis being done

Fig. 4: Dye testing for patency following anastomosis

RESULTS

A total of 40 women undergoing sterilization reversal by microsurgical technique were included and followed up for at least 1 year. Intrauterine pregnancies were achieved in 21 (52.5%) cases of which 18 (85.5%) had live births, 1 (4.7%) had ectopic pregnancy, and 2 (9.5%) had abortions. Remaining 19 women who have not conceived were followed up with hysterosalpingogram to look for anatomical patency of the fallopian tube.

In our study, among the patients who conceived the majority were of age-group of 26–29 years (57.1%), and the patients who did not conceive were also in the same age-group years (47.4%) (Table 1). In all, 97.5% of the participants were with para 2 or less, and the commonest reason for seeking reversal of sterilization was the death of one or all the children’ (80%). Maximum number of the patients who conceived after recanalization had history of laparoscopic sterilization in 62% (Table 2). Commonest site of anastomosis done was bilateral isthmo–isthmic with pregnancy rate of 52.3% (Table 3). The pregnancy was achieved in 61.5% of the women when the tubal length was more than 6 cm (Table 4). In the present study, there were 12 women with sterilization and reversal interval %3C;4 years, and all of them conceived (Table 5) and the interval from sterilization to recanalization is statistically significant with p value < 0.001. Condition of tubes, ovaries, and uterus were normal in 70% of women. Hysterosalpingography (HSG) performed on 19 patients who did not conceive by end of 1 year showed 52.6% had bilateral patent tube, 42.1% of participants had unilateral patent tubes, and 5.3% had bilateral tubal blockage (Table 6).

DISCUSSION

There are multiple factors that dictate success or failure of tubal recanalization. In our study, the overall conception rate was 52.5% (21/40 cases) of which 18 (85.5%) had live births, 2 (9.5%) abortions, and 1 (4.7%) ectopic pregnancy. Comparable to study by Shilpa et al., where conception rate was 55.5% (25/45 cases) of which 18 (72%) had live births, 4 had abortion and 3 cases were ectopic pregnancies,2 similar to a study by Kim et al.,6 where overall pregnancy rate was 54.8% with a delivery rate of 72.5%; another study done by Jayakrishnan et al.7 also had overall pregnancy rate of 58.8%.

A higher rate of conception after recanalization in our study is seen in women aged less than 30 years, whereas Jain et al.8 showed a higher pregnancy rate in the age-group of less than 25 years.

Table 1: Comparison of age distribution of patients studied
Age in yearsConceived
Not conceived
No(%)No(%)
20–25  6  28.6  4  21.1
26–2912  57.1  9  47.4
30–35  3  14.3  6  31.5
Total21100.019100.0
Table 2: Comparison of type of sterilization in two groups of patients studied
Type of sterilizationConceived
Not conceived
No(%)No(%)
Puerperal  6  28.5  8  42.1
Concurrent with lower segment cesarean section  2    9.5  4  21.0
Laparoscopic13  61.9  7  36.8
Total21100.019100.0

In our study, most reversal seekers (97.5%) were para 2 or less. This high figure of low parity coincides with the study of Biswas and Mondal,9 where it was 86.8% and a study by Brar et al.10 had 75% of the patients with para 2 or less. In a study by Maya et al.,11 54.5% of women were para 2.

In our study, death of one or all children was the commonest reason for the couple to seek reversal of sterilization (80%). It coincides with a similar study by Shilpa et.al.,2 which states that death of only child or all children was the commonest reason for reversal of sterilization (66%), while in a study by Koteshwar et al., the reason was death of all the children in 70% of participants.12

Table 3: Comparison of anastomosis in two groups of patients studied
AnastomosisConceived
Not conceived
No(%)No(%)
B/L isthmo-isthmic11  52.3  1    5.2
B/L ampulloampullary  4  19.0  2  10.5
isthmo-isthmic+ isthmoampullary  3  14.2  2  10.5
B/L isthmoampullary  2    9.5  2  10.5
B/L infundibuloampullary  1    4.8  4  21.0
Isthmoampullary + fimbrioampullary  0    0.0  2  10.5
B/L cuff salpingostomy  0    0.0  1    5.2
Isthmoisthmic + fimbrioampullary  0    0.0  1    5.2
Isthmoisthmic + cuffsalpingostomy  0    0.0  1    5.2
Isthmoampullary + ampulloampullary  0    0.0  1    5.2
Ampulloampullary + cuffsalpingostomy  0    0.0  1    5.2
Ampulloampullary +fimbrioampullary  0    0.0  1    5.2
Total2110019100
Table 4: Final length of reconstructed tube in conceived group
Final length of reconstructed tubeTotal no. of tubesConceived noPercentage
%3E;6 cm5232  61.5
4–6 cm22  9  40.9
<4 cm  6  1  16.6
Total8042100
Table 5: Comparison of Interval from sterilization in two groups of patients studied
Interval from sterilizationConceived
Not conceived
No(%)No(%)
<4 years12  57.1  0    0.0
4–6 years  9  42.8  1    5.2
    >6 years  0    0.018  94.7
Total21100.019100.0
Table 6: Hysterosalpingography (HSG) was performed on 19 patients who did not conceive by one year
HSGNo. of patientsPercentage
Bilateral patency10  52.6
Unilateral patency  8  42.1
Bilateral block  1    5.3
Total19100

Higher pregnancy rate (57.1%) has been reported when the interval between sterilization and reversal operation is less than 4 years in our study. Whereas in a study by Shilpa, the pregnancy rate of 75% was noted when reversal was done within 2 years. Kalaichelvi et al.13 found that 87% of women conceived when recanalization was done within 1 year of sterilization, while the incidence dropped to 16% when the interval was more than 10 years. It may also be added that as interval increases, the age of the patient increases further reducing the probability of conception.

The present study showed a success rate of 62% in women who had undergone laparoscopic sterilization when compared to 32% in women following reversal of Pomeroy’s technique. Kalaichelvi et al.13 in a large series comprising 465 women quoted a success rate of 68% in women who had undergone laparoscopic sterilization when compared to 42% following reversal of Pomeroy technique. Our study also correlated with the results of all other studies and showed that previous laparoscopic sterilization had better chances of reversal. This is because in laparoscopic sterilization, the length of damage tube is smaller.8,9

In the present study, bilateral isthmo-isthmic anastomosis resulted in pregnancies in 52.3% of women and bilateral ampullo-ampullary in 19%. This is because in isthmo-isthmus and in ampullo-ampullary anastomosis, the tubes being anastomosed were of similar diameters.

Our study correlated with a study by Shilpa,2 where 72% intrauterine pregnancies were seen with isthmo-isthmic anastomosis. This also corelated with another study by Kalaichelvi et al.,13 where 76.2% intrauterine pregnancies were seen in women with isthmo-isthmic anastomosis.2

In the present study, the pregnancy after recanalization was achieved in 61.5% of the women when the tubal length was more than 6 cm in comparison to 40.9% when the length was 4 to 6 cm, and it dropped down to just 16.6% when the length of tube was less than 4 cm. These results highlight the importance of significance of the type of sterilization procedure on the prospects for pregnancy following reversal surgery. Similarly, in a study by Shilpa,2 about 82.2% women had final tubal length of >6 cm. The pregnancy rate was 83.3% when tubal length was >8 cm and only 12.5% when it was %3C;5 cm. Jain et al.8 observed the importance of reconstructed tubal length where 83.3% pregnancy rate was noted when tubal length was %3E;8 cm.2

Reasons for nonconception of 19 women even after anatomical reconstruction was two women were not staying with their partner, two women were not interested in conception, four women were having anovulatory cycles following reversal of sterilization, and rest of the women are undergoing ovulation induction.

CONCLUSION

To conclude, every patient undergoing sterilization is a potential candidate for reversal. So, we propose that every effort should be made to perform sterilization over isthmus as site of tubectomy, and hence the site of recanalization is an important factor in determining the results after recanalization. Keeping maximum length of the tube preferably by using methods causing minimum damage to the tube-like laparoscopic sterilization as are also important factors for successful recanalization.

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