6.1 Background
Surgical sterilization is the most commonly used contraceptive method among couples in the United States [1]. According to the 2002 National Survey of Family Growth, 27% of fertile women relied on female sterilization for birth control, while an additional 9% relied on partner vasectomy [1,2]. While these methods are widely considered safe and effective, regret following female sterilization methods varies widely and has been reported to be as high as 26% [3]. Regret is highest among women who undergo the procedure when less than 30 years old and less than 2 years after the birth of their youngest child [3].
Sterilization procedures are commonly performed laparoscopically using electrocoagulation, Fallope rings, or Hulka or Filshie clips. In addition, partial salpingectomy can be performed at the time of cesarean delivery, transumbically shortly following vaginal delivery, or by interval minilaparotomy using the Parkland or Pomeroy techniques [2,4]. Finally, hysteroscopic insertion of the Essure tubal occlusion device (Bayer, Whippany, NJ) into the tubal ostia has the advantage of being performed as an office procedure.
6.2 Preoperative Considerations
Contraindications to performing tubal anastomosis are final tubal length less than 4 cm, prior ectopic pregnancy or pelvic inflammatory disease, stage 3 or 4 endometriosis, significant adnexal adhesions, and more than a mild male factor [5]. The operative report from the tubal ligation and a semen analysis should be obtained to determine if the patient is a candidate for tubal reversal. Eligible patients are counseled regarding the procedure as well as IVF including the success rates, risks, advantages and disadvantages, and cost.
The advantages of tubal anastomosis are that it is a minimally invasive outpatient procedure, which allows patients to attempt to conceive spontaneously each month, as well as to conceive more than once with no additional intervention (Table 6.1). In most cases, it is less expensive than IVF, especially if more than one cycle is required. The disadvantage is that it carries all of the risks of surgery such as bleeding, infection, organ damage, and reaction to anesthesia as well as postoperative discomfort.
Table 6.1 Comparison of Tubal Anastomosis and IVF
| Anastomosis | IVF | |
|---|---|---|
| Inconvenience | One-time minimally invasive procedure | • Daily injections |
| • Frequent monitoring | ||
| Opportunities to conceive | • Can try every month | Limited attempts |
| • Can conceive more than once | ||
| Risks | • Surgical risks | • Multiple pregnancy |
| • Ectopic pregnancy | • Ovarian hyperstimulation syndrome (OHSS) | |
| Advantages | • More cost-effective | • Faster time to conception |
| • More natural | • Preserves fertility | |
| • Effective if other infertility factors are present |
The advantages of IVF are that it is nonsurgical and has high success rates even in patients who are not candidates for tubal anastomosis. Patients may have more than one opportunity to conceive per IVF cycle if extra embryos are available for cryopreservation. The disadvantages of IVF are that it is more labor-intensive with weeks of daily injections, frequent visits for follicle monitoring with pelvic ultrasonography and blood estradiol levels, an outpatient procedure to retrieve the oocytes, and another visit for embryo transfer. Subsequent pregnancy attempts require the thaw and transfer of cryopreserved embryos or additional IVF cycles if no cryopreserved embryos are available. Anecdotally, nearly all eligible patients in our practice opt for tubal anastomosis citing lower cost and that it is more “natural” than IVF as the reasons for their preference. The main risks of IVF are multiple pregnancy, since more than one embryo is often transferred, and ovarian hyperstimulation, which can be potentially life-threatening and require hospitalization. These risks further increase the overall cost of IVF.
6.3 Predictors for Success
Pregnancy rates after tubal anastomosis are stable at 70–90% until they rapidly decrease at age 40 [6–9]. A large population-based study from Australia confirmed the precipitous drop at 40 but the overall pregnancy rates were lower for all groups [10]. This was likely due to multiple surgeons of different skill levels using unspecified techniques. Even including that study, the one-year cumulative pregnancy rates in patients 40 years of age and older is 20–50% [6–10]. These rates are generally better than those achieved with IVF for this age segment. A retrospective cohort of 79 IVF patients and 84 undergoing anastomosis noted a significantly higher cumulative live birth rate with tubal anastomosis versus IVF of 52% for women under 37 years of age, 72% and 52%, respectively p=0.012 [11]. For women 37 and older, the anastomosis success rate of 51% was not significantly different from 37% with IVF.
Some studies reported an association between final tubal length and pregnancy rates but others found no difference [7,12]. The sterilization method also significantly impacts success rates, with the best outcomes being achieved following reversal of tubal occlusion by Fallope rings or Filshie or Hulka clips [9].
6.3.1 Financial Considerations
A retrospective cost analysis from Belgium comparing IVF with tubal anastomosis found that the average cost per delivery was double for IVF with a mean of two IVF cycles required [11]. Another cost analysis from the United States confirmed that the cost per pregnancy was double with IVF for women up to age 40. However, the cost for tubal anastomosis was double for women over 40 [13]. An Australian analysis of women between 40 and 47 years reported that the cost per live birth was approximately 10 times more expensive with IVF than with anastomosis [14].
6.4 Surgical Approach
In addition to standard laparotomy with overnight hospitalization, tubal anastomosis may, and should, be performed by minimally invasive outpatient approaches such as minilaparotomy and laparoscopy, with or without robotic assistance. The few studies comparing laparotomy with laparoscopy found no difference in intrauterine or ectopic pregnancy rates. As expected, the operating times were longer with laparoscopy but the hospitalization times were shorter [15]. Since laparoscopic tubal anastomosis is difficult, several shortcuts have been tried such as a one-stitch technique and using clips or glue. The goal of laparoscopic surgery is to duplicate the open procedure. Only the route of access is different. In an effort to overcome the technical difficulties of performing microsurgery through the laparoscope, robotic assistance has been utilized. There are no studies comparing laparoscopic tubal anastomosis with and without robotics. A retrospective study comparing tubal anastomosis with robotics with outpatient minilaparotomy found that robotics added over an hour under anesthesia and $1,450 [16]. Patients returned to work 1 week earlier after robotic anastomosis. The pregnancy rate of 81% with minilaparotomy was not significantly different than the 61% with robotics but that was likely due to the small sample size of 55 patients. Another retrospective study comparing robotic tubal anastomosis with standard laparotomy found no difference in overall pregnancy rates, but the ectopic pregnancy rate was double with robotics [17]. Also, tubal anastomosis with robotics was $2,000 costlier despite the laparotomy patients requiring overnight hospitalization. Regardless of the approach, the steps of performing tubal anastomosis are the same. The author’s preferred technique of minilaparotomy is described next.
6.4.1 Operative Technique
The procedure begins by inserting a uterine manipulator for manipulation and chromotubation (see Video 5.3). Diagnostic laparoscopy is performed to assure adequate tubal length and the absence of significant pelvic disease. A 5 cm transverse minilaparotomy is performed approximately 3 cm above the symphysis and carried down to the fascia. The fascia is incised vertically in the midline and the rectus bellies are separated. The peritoneum is then incised vertically and a round wound retractor such as the Mobius (CooperSurgical, Inc., Trumbull, CT) or Alexis (Applied Medical, Rancho Santa Margarita, CA) is placed (Figure 6.1). Dilute vasopressin (20 units in 100 ml of injectable saline) is infiltrated into the mesosalpinx beneath the occluded ends (Figure 6.2). The ends are then mobilized with the unipolar micro-needle with 20 W of cutting current (Figure 6.3). The proximal end is opened with Wescott scissors and patency is confirmed with transcervical chromotubation using dilute indigo carmine or methylene blue dye (Figures 6.4 and 6.5). The distal end is then opened taking care to keep the opening small in order to have similar luminal diameters between the proximal and distal segments (Figure 6.6). Patency of the distal segment is established by retrograde chromotubation by injecting dilute indigo carmine or methylene blue dye transfimbrially with an 18G angiocatheter (Figure 6.7).
