Voluntary female sterilisation via minilaparotomy: report from Burkina Faso.

We present the first study of voluntary female sterilisation in Burkina Faso. The average woman undergoing tubal ligation was a 37 year old, married, house wife para 8 with five living children. The main reasons for TL were: achieved desired family size (45.9%) and medical reason (29.5%). The TL was usually performed (77.8%) in the postpartum, using the Pomeroy technique. With a follow up of three to fifteen months, no pregnancy has been reported and no request for reversal expressed. The authors make some suggestions to increase the prevalence of TL in Burkina Faso.

PIP: In the first study of female sterilization in Burkina Faso, case records of the 63 women undergoing minilaparotomy in the 12-month period between June 1, 1995, and May 31, 1996, at the country's second largest obstetric and gynecologic unit (Centre Hospitalier National Sanou, Bobo Dioulasso) were reviewed. Acceptors ranged in age from 27 to 45 years (mean, 37.36 years) and had an average of 5 living children; 55.6% were in polygamous marriages and 65.1% were Muslim. 32.3% reported prior use of a modern contraceptive method, primarily the pill. The decision to undergo sterilization was made by both partners in 50.8% of cases and by the husband alone in 23%. Achievement of desired family size was the primary reason (45.9%) for sterilization; another 29.5% were motivated by medical reasons. 77.8% of procedures were performed in the postpartum period. The Pomeroy method was used in all cases. Women were discharged from the hospital on the same day as the procedure. There were no sterilization-related complications in this series, and no pregnancies or requests for reversal have occurred in 3-15 months of follow up. It is recommended that Burkina Faso establish a national voluntary female sterilization program, equip peripheral health centers with minilaparotomy kits, and train physicians and medical students to perform the procedure.

A case of failure of tubal sterilization using Pomeroy's technique.

With reference to a case of pregnancy of a patient formerly subjected to tubal sterilization using Pomeroy's technique, the authors define the possibility for tubal stumps to recanalise. Despite the low percentage of failure in tubal sterilization using Pomeroy's technique, the authors conclude that it is advisable to make the earliest possible diagnosis of both intrauterine and extrauterine pregnancy on the basis of suspected symptoms in order to, especially for tubal pregnancies, avoid any tubal sterilization.

PIP: The Pomeroy technique of tubal sterilization is widely used and considered highly effective. Reported in this paper is a case of a pregnancy in a woman from Naples, Italy, who underwent this procedure. The patient requested sterilization during her third cesarean section delivery in 1992 and tubal occlusion was confirmed by a hysterosalpingograph conducted 3 months later. When the patient presented 19 months later with a missed period, an intrauterine pregnancy was found. During the subsequent cesarean section delivery, bilateral tubal exploration revealed that some tubal residual products from the sterilization were still bound by the thread and the stumps graphing. It was assumed that recanalization of the two stumps below the tubal binding was responsible for the conception. A new sterilization was performed after removal of the stumps by the Pomeroy technique 0.5 cm below the canalization.

Laparoscopic Pomeroy tubal ligation as a teaching model for residents.

We reviewed our preliminary experience with laparoscopically directed bilateral midtubal resection for tubal ligation (endoscopic Pomeroy) as a potential teaching tool for the acquisition of endoscopic skills during residency training. Thirty-five laparoscopic Pomeroy and 206 banding procedures were reviewed. Age, parity and weight were similar in the two groups. The operative time for banding was reduced slightly after experience with > 10 procedures. In contrast, the operative time for laparoscopic Pomeroy procedures decreased dramatically after individual experience with only a few (< or = 5) procedures. The mean operative time for the Pomeroy group approached that of the more traditional banding technique at five procedures. Our data indicate that laparoscopic Pomeroy sterilization can be an effective teaching tool for operative laparoscopy, allowing residents to repeatedly perform an easy and safe procedure that incorporates basic techniques. Advanced operative endoscopic procedures could then be taught more efficiently after the acquisition of basic skills.

PIP: 25 gynecology residents performed laparoscopic banding (tubal rings) sterilization on 206 women and laparoscopic Pomeroy sterilization on 35 women, all of whom underwent tubal sterilization at the University of Mississippi Medical Center between September 1988 and October 1990. Three faculty members and a fourth year resident retrospectively analyzed the data of both groups to determine the effect of the Pomeroy method on operative laparoscopic skills acquired by the residents during training. Both groups were similar in age, parity, and weight. Each of the 23 residents performed 1-22 laparoscopic banding procedures. As residents gained experience, the time to perform both banding and Pomeroy methods decreased significantly (p = 0.026). After a resident had conducted 5 Pomeroy procedures, the surgery time had approached that of laparoscopic banding. These findings show that gynecology faculty can use laparoscopic Pomeroy tubal ligation as an effective teaching tool for laparoscopy by providing residents an opportunity to repeatedly perform an easy and safe procedure that includes basic techniques. After developing the basic skills, the residents can then learn more efficiently advanced operative endoscopic techniques.

Twice-failed tubal ligation: a case report.

The case is presented of a twice-failed tubal ligation in a woman with six previous children. The first failure followed laparoscopic tubal occlusion by silastic falope rings, while the second failure was subsequent to tubal ligation and division via minilaparotomy. No similar reports have been reported in the East African Literature. Possible reasons for failure are discussed.

PIP: A case of 2 failed tubal ligations in a para 6 Kenyan woman is described. She had an interval laparoscopic sterilization with silastic rings after delivery of her 6th child at age 38. After 3 menstrual periods she became pregnant. She decided to be sterilized again after delivery of her 7th child, a 3.5 kg male. Because of moderate obesity, a minilaparotomy with intravenous anesthesia was performed. The right fallopian tube was only partially occluded with a silastic ring, but the left tub was properly occluded. A Pomeroy tubal ligation was done, excising 2 cm of each tube, and ligating with No. 1 catgut. The woman experienced 2 more menses, and conceived again. She was delivered of a term female, and submitted to a hysterosalpingogram, which showed a tubal-peritoneal fistula on the right. The woman expressed fatalism about future childbearing, and eventually refused to return for contraceptive care or another sterilization.

Postpartum tubal sterilization. A comparative study of the Hulka clip and modified Pomeroy technique.

To assess the feasibility of Hulka clip application for postpartum sterilization, 50 women were enrolled in a randomized, prospective study comparing modified Pomeroy tubal ligation and Hulka clip application. Hulka clip tubal occlusion in the postpartum period compared favorably with the commonly performed postpartum sterilization technique. Because of the simplicity of the technique and its greater potential reversibility, Hulka clip application may have advantages over standard postpartum sterilization techniques and should be considered for use in the postpartum period.

PIP: To assess the feasibility of Hulka clip application as a method of postpartum sterilization, the experience of 22 women undergoing this procedure was compared to that of 28 controls who underwent a modified Pomeroy technique. Although Hulka clip application offers the advantage of destroying only a 2-4mm segment of the fallopian tube and is thus highly reversible, surgeons have been concerned that the jaws of the clip are not long enough to completely transverse edematous postpartum tubes. Preliminary to this study, 5 women consented to have Hulka clips applied on tubal segments that would then be ligated via the Parkland technique. Histologic examination showed that, although the 10 tubes were wider than nonpregnant tubes at interval sterilization, the lumen of the tube was completely encompassed within the jaws of the clip. The time required for clip application in the 28 subjects was 21.7 + or - 10.5 seconds compared to 84.2 + or - 28.3 seconds for ligation and excision, while the total surgical time required was 16.2 + or - 4.2 minutes in Hulka clip acceptors compared to 21.3 + or - 10.9 minutes in Pomeroy procedure patients. Not significant was the difference in recovery room stay for Hulka clip patients (68.8 + or - 19.3 minutes) versus Pomeroy patients (79.4 + or - 24 minutes). Finally, there was a significant difference in the number of days until full recovery: 7.4 + or - 5.9 days in clip patients versus 25.9 + or - 12.7 days in Pomeroy patients. Although there is a need for studies of larger numbers of women to document efficacy, these findings suggest that Hulka clip postpartum tubal occlusion is indeed feasible. In fact, it may become the method of choice in postpartum sterilizations. Such procedures are likely to involve younger women, who are at greatest risk of subsequent regret and requests for reversal.

Macroscopic tuboplasty: reversal of female sterilization.

Data is presented regarding 57 women who underwent reversal of sterilization procedure. In the majority (90%), the reason for request for reversal of procedure was loss of male child or more than one child. Thirteen subjects never came back for follow-up. Out of 39 subjects in whom follow-up is available for more than 3 months, in 35 (90%) the tubes are patent. There were 25 pregnancies in 21 subjects and incidence of viable pregnancy was 88% with only ectopic pregnancy (4%). In these 35 cases whose tubes were found to be patent post tuboplasty, 18 had laparoscopic ring application, 16 had abdominal tubal ligation and one had undergone vaginal tubal ligation. Thirteen subjects (62%) conceived within 6 months after reversal. In this series, no loupe or operating microscope was used.

PIP: Between 1982-88, physicians performed tubal sterilization reversals using macrosurgical techniques on 57 women at Nehru Hospital in Chandigarh, India. Some patients were lost to follow up. 59.65% had earlier undergone abdominal tubal ligation (Pomeroy method) and 38.6% laparoscopic ring sterilization. 91.2% requested sterilization reversal because they had lost at least 1 previous child, especially a son, and 8.77% because of remarriage. Most of the women wished to have a son. 38.6% did not have any surviving children at the time of reversal. 21 (54%) of the 39 women who could be followed for 6 months became pregnant. In fact, these 21 women experienced 25 pregnancies. 61.9% of these women conceived within the 1st 6 months following reversal surgery. The pregnancy rate for women whose interval between sterilization and reversal was =or- 36 months was 55% compared with 45% for 36 months. 22 (88%) of the pregnancies resulted in term delivery. 1 was an ectopic pregnancy (4%), 1 (4%) pregnancy ended in spontaneous abortion, and another pregnancy (4%) was terminated in the 2nd trimester due to an anencephalic fetus. 61.9% of the pregnant women had had a laparoscopic ring sterilization compared with 33.3% of nonpregnant women. The leading type of sterilization reversal surgery was bilateral end to end anastomosis (90.5% of pregnant women and 61.1% of nonpregnant women). The sites that resulted in the best and worst pregnancy rates were bilateral end to end isthmo-isthmic anastomosis (56.14%) and the bilateral ampullo-ampullary (31.25%). A higher percentage of nonpregnant women underwent ampullo-ampullary reanastomosis than pregnant women (39% vs. 23.8%). Overall, the postoperative tubal patency rate was 90% of the 39 cases followed for 6 months. Of the 18 women who had not yet conceived at 6 months follow up, 14 (77.7%) had patent tubes.

Necrotizing fasciitis of the total abdominal wall after sterilization by partial salpingectomy. Case report and review of literature.

A case of necrotizing fasciitis with full-thickness loss of the entire abdominal wall is reported after an uncomplicated sterilization by bilateral partial salpingectomy through a minilaparotomy incision in a healthy young patient. Salvage was accomplished by early wide surgical debridement and multiple reconstructive procedures.

PIP: The medical literature includes reports of necrotizing fascitis after Bartholin abscesses, vaginal delivery, cesarean section, abdominal hysterectomy, sterilization by bilateral total salpingectomy, and diagnostic laparoscopy. This paper presents the 1st documented report of necrotizing fascitis after sterilization by bilateral partial salpingectomy. The patient, a healthy 41-year-old, presented with severe abdominal pain, nausea, and vomiting 1 day after undergoing bilateral partial resection and ligation of the fallopian tubes through a suprapubic minilaparotomy incision (Pomeroy procedure). Disseminated intravascular coagulopathy developed soon after admission. Surgery, performed once the patient has been stabilized through corticosteroids and broad-spectrum antibiotics, revealed extensive necrotizing fascitis involving the entire abdominal wall. There was no perforation of the bowel or uterus. Escherichia coli was cultured from the patient's abdominal wall, urine, and blood. The patient was treated successfully with piperacillin, gentamicin, and clindamycin. 15 days later, multiple reconstructive procedures were initiated to close the abdominal defect. This patient's good recovery was due to the speed of the diagnosis and wide surgical debridement of all devitalized tissue. Since she showed no evidence of salpingitis at the time of the sterilization procedure, the source of bacterial inoculum in this case was most likely the patient's skin.

The value of hysterosalpingography before reversal of sterilization procedures involving the fallopian tubes.

Knowledge of the length of the uterine end of the fallopian tube and the presence of tubal adhesions and fistulas is important when surgical reversal is undertaken in patients who have had tubal ligation. We retrospectively studied hysterosalpingograms in 127 such patients to determine their value in providing this information. The ligation was performed by using the Pomeroy technique in 57 patients. Sixty-one patients had bipolar electrocautery, six had Falope rings inserted, and three had Hulka clips applied. In all cases, the uterine ends of the tube were visualized to a point of obstruction. The sites of occlusion after Pomeroy ligation were midtubal (46%), cornual (16%), proximal ampullary (16%), proximal isthmic (14%), and intramural (8%). After the electrocautery procedure, the sites of occlusion were proximal isthmic (45%), intramural (20%), midtubal (19%), cornual (15%), and proximal ampullary (1%). When Falope rings and Hulka clips were used, the most frequent site of occlusion was midtubal (50%). Tubal adhesions, consistent with successful occlusion, were detected in 16 patients on the basis of a small confined area of extravasation of contrast material at the site of ligation. Tuboperitoneal fistulas, identified by the presence of contrast material spilled from the uterine end of the tube into the peritoneal cavity, were detected in five patients. Our results show that hysterosalpingography is a useful technique for determining the status of the uterine end of the fallopian tube after ligation when reversal of ligation is planned.

Changes in menstrual blood loss after four methods of female tubal sterilization.

One-hundred females requesting tubal sterilization were included in this study. They were enrolled into 4 groups, each n = 25. They were allocated to a particular method of sterilization on a randomized basis. The four modalities used were: laparoscopic Falope ring application, bipolar electrocoagulation, Hulka clip application and Pomeroy tubal ligation via minilaparotomy. The menstrual blood loss (MBL) was quantitatively estimated, using the alkaline hematin method, prior to sterilization and after 3, 6 and 12 months. No significant changes in MBL were observed after the four sterilization techniques. Moreover, they did not differ significantly in this context.

PIP: 100 women seeking surgical sterilization were allocated to 1 of 4 groups--laparoscopic Fallope ring application, bipolar electrocoagulation, Hulka clip application, and Pomeroy tubal ligation through minilaparotomy--and changes in menstrual blood loss prior to sterilization and after 3, 6, and 12 months were compared. The 4 groups were comparable in terms of age, parity, and duration of marriage. All were at least 6 months postpartum or postabortion, had not used hormonal contraception or the IUD for at least 6 months before sterilization, had regular menstrual periods with moderate blood loss, and no gross pelvic pathology. The mean poststerilization increase in menstrual blood loss was greater in terms of volume after electrocoagulation (7.93 ml), lower after Fallope ring and Pomeroy (4.43 and 6.53 ml, respectively), and lowest after clip application (1.97 ml). However, when the 4 sterilization techniques were compared with each other, there were no significant differences in this variable. The percentage of women who developed menorrhagia (menstrual blood loss greater than 80 ml) decreased from 12% at 3 months poststerilization to 8% at 12 months after the procedure. By 12 months, majority (61%) were showing menstrual blood loss levels equal to or less than those recorded before sterilization. These findings lend credence to the assumption that female sterilization is an effective, safe, and feasible method of fertility control with few longterm effects on the menstrual cycle.

Menstrual patterns and progesterone circulating levels following different procedures of tubal occlusion.

This study was undertaken to assess the effects of different tubal occlusion procedures on ovarian function. Three groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and one separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for one year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20 and 25 of menstrual cycles initiated 1, 3, 6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other two study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the percentage of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group.

PIP: This study was undertake to assess the effects of different tubal occlusion procedures on ovarian function. 3 groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and 1 separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for 1 year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20, and 25 of menstrual cycles initiated 1,3,6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other 2 study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the % of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group. (Author's).

[An epidemiological investigation on the effect of tubal ligation in Henan province].

PIP: 8766 cases of tubal ligation performed between 1978-83 were studied by means of a retrospective epidemiological investigation. It was demonstrated with life table statistical analysis that the cumulative rate of repeat pregnancy was 0.4/100 women in the 1st year and 1.07/100 women in the 6th year after tubal ligation. The morbidity of complications after tubal ligation was 2.66%. Infection was the most common complication. According to results obtained from multiple gradual judgement analysis and single factor analysis, it was indicated that the primary factor influencing tubal ligation was the type of operation or the hospital where the operation was performed. The Madlener procedure resulted in a markedly higher rate of repeat pregnancy than the Pomeroy procedure, the modified Pomeroy, or the Uchida. The operation performed in the hospitals below county level gave a markedly higher rate of repeat pregnancy than those above the county level. The reported results indicate that tubal ligation is a safe, reliable, and permanent method for birth control. (author's modified)^ieng

Ruptured tubal pregnancy following tubal sterilization.

PIP: Prior tubal sterilization should be regarded as a possible etiologic factor in the pathogenesis of ectopic pregnancy. The authors present the case of a 32-year-old woman, para 4, who presented to Kenyatta National Hospital in October 1985 with complaints of lower abdominal pain and vomiting. She had undergone tubal ligation in February 1985. Examination revealed a ruptured ectopic pregnancy in the lateral part of the left tube. There was active bleeding from the rupture. The right distal stump was intact, and the right proximal stump had no obvious defect. There was a corpus luteum in the left ovary. Ectopic gestation after tubal sterilization apparently occurs when there is recanalization and formation of a proximal tuboperitoneal fistula, allowing sperm passage and fertilization of the ovum in the peritoneal cavity, on the ovarian surface or within the ductal tubal lumen. Although the technical details of this patient's sterilization were not available, laparotomy indicated that a modified Pomeroy procedure using absorbable sutures had been performed. The failure rate for the Pomeroy procedure is estimated at 0.25-2%. Since the incidence of ectopic pregnancy following tubal sterilization is about 1 in 13 in some parts of the world, potential sterilization acceptors should be counseled about this complication and a diagnosis of ectopic gestation should be considered whenever a patient with a previous history of tubal ligation presents with signs or symptoms of pregnancy.^ieng

Pregnancy following minilaparotomy tubal sterilization--an update of an international data set.

Seventeen pregnancies were reported from an international tubal sterilization data set comprising 1,862 minilaparotomy cases between 1978 and 1984. Of these 17, seven (41.2%) were diagnosed as luteal phase pregnancies. Of the 10 pregnancies due to sterilization failure, one was an ectopic pregnancy which occurred much later (20 months poststerilization) than the intrauterine pregnancies (10 months or less). Poststerilization pregnancy risk was greater among gravid women (those undergoing sterilization at the time of abortion or soon after childbirth) than among non-gravid women (those undergoing interval sterilization). These findings are, in general, consistent with those of previous studies using a much larger data set of primarily laparoscopic sterilizations. Pregnancies occurred with every type of mechanical tubal occlusion techniques included for study (the tubal ring, the Rocket Clip, the Secuclip and the Filshie Clip), and a frequently reported reason for failure was incorrect placement of the device. No pregnancies occurred in women sterilized with the non-mechanical Pomeroy/modified Pomeroy techniques. Findings of this analysis suggest that in minilaparotomy sterilization, for the mechanical tubal occlusion techniques to be as effective as the Pomeroy/modified Pomeroy techniques, more care and skill are required for the operator.

PIP: 17 pregnancies were reported from an international tubal sterilization data set comprising 1,862 minilaparotomy cases between 1978 and 1984. Of these 17, 7 (41.2%) were diagnosed as luteal phase pregnancies. Of the 10 pregnancies due to sterilization failure, 1 was an ectopic pregnancy which occurred much later (20 months poststerilization) than the intrauterine pregnancies (10 months or less). Poststerilization pregnancy risk was greater among gravid women (those undergoing sterilization at the time of abortion or soon after childbirth) than among non-gravid women (those undergoing interval sterilization). These findings are, in general, consistent with those of previous studies using a much larger data set of primarily laparascopic sterilizations. Pregnancies occurred with every type of mechanical tubal occlusion technic included for study (the tubal ring; the Rocket Clip; the Secuclip; and the Filshie Clip), and a frequently reported reason for failure was incorrect placement of the device. No pregnancies occurred in women sterilized with the non-mechanical Pomeroy/modified Pomeroy technics. Findings of this analysis suggest that in minilaparotomy sterilization, for the mechanical tubal occlusion technics to be as effective as the Pomeroy/modified Pomeroy technics, more care and skill are required for the operation.

[Postpartum sterilization in a program of medical training]. / Esterilización postparto en un programa de adiestramiento médico.

PIP: This study presents information about the postpartum sterilization program of a teaching hospital in Nuevo Leon, Mexico, and compares results to data reported in the literature. 147 patients undergoing sterilization between February-August 1984 were included. 6 of the women were under 20 years old, 18 were 21-25, 63 were 26-30, 30 were 31-35, and 30 were 36 or over. 22 had had 1-3 children, 81 had 4-6, 27 had 7-9, and 17 had over 9. 96.6% were married. 92 had never used a contraceptive method, 47 had used pills, 7 had used IUDs, and 1 had used a barrier method. Only 29 had been born in the Nuevo Leon metropolitan area but 126 were current residents. 101 had incomplete or complete primary educations, 8 had secondary educations, 36 were illiterate, and 2 had professional educations. Only 38 had prenatal health care preceding the delivery. Hemoglobin levels in 20 cases were less than 9.0, 28 were 9.1-10.0, 45 were 10.1-11.0, 34 were 11.1-12.0, and 20 were 12.1 or above. 17.6% of patients required preoperative transfusions of packed blood. The indication for sterilization was multiparity in 96.6% of cases. 13 patients had epidural anesthesia during delivery, 1 had a subarachnoid block, and 133 had no anesthesia. 139 had epidural blocks during the sterilization operation, 6 had subarachnoid blocks, and 2 had general anesthesia. There was 1 case of cardiorespiratory arrest but recovery was satisfactory. The only obstetric complication was 1 perforation of the jejunum, which was repaired. There were no other cases of pre- or postoperative complications except for 21 cases of difficulty in providing epidural anesthesia. The Pomeroy technique was used in 139 sterilizations, fimbriectomy in 5, and salpingectomy in 5. Umbilical hernioplasties were done in 3 patients without complications. The interval between surgery and leaving the hospital was between 12-24 hours in 83.7% of cases. The interval between delivery and sterilization was 12-24 hours in 71.4% of cases. Only 9 cases required more than 4 days of hospitalization. The immediate postpartum is not considered the optimal moment for female sterilization because of the increased vulnerability of the patient. The experience with this series suggests that for some patients, tubal sterilization by minilaparotomy in the immediate postpartum is a valuable method because it meets the demand for definitive contraception among high parity women of low socioeconomic level and with limited access to medical care. It requires only brief hospitalization and involves very low rates of morbidity.^ieng

Torsion of the fallopian tube--a late complication of sterilisation.

PIP: Torsion of an intact fallopian tube, unaccompanied by torsion of the ipsilateral ovary, was noted as a complication of bilateral tubal occlusion by the Pomeroy method in a 45-year old Indian woman. The sterilization was performed 5 years previously, at the time of Cesarean section delivery. The patient presented with a history of pain in the right iliac fossa. Laparotomy showed that the distal segment of the right fallopian tube was twisted 3 times on the distal mesosalpinx and appeared tense and gangrenous. The right ovary was normal and a 2 cm gap was noted between the proximal and distal segments of the tube. As a rare complication of the Pomeroy method, the gap in the tube can allow the distal mesosalpinx to act as a pedicle, and with a long mesosalpinx, the fimbriated segment of the tube lies free and may swing and twist to produce torsion. The occurrence of torsion is further promoted by a vascular disturbance leading to venous congestion, edema, and increased weight of the free fimbrial end of the tube. In those patients with a history of sterilization, torsion of the fallopian tube should be considered in the differential diagnosis of acute lower abdominal pain. Torsion of the fallopian tube has also been reported following other methods of tubal occlusion, including cautery and clips.^ieng

Microsurgical reversal of sterilization: a six-year study.

A prospective study of 113 personal consecutive microsurgical reversals of female sterilization during the 6-year period from 1979 to 1984 was carried out to determine factors affecting the pregnancy rate. The sterilizations were performed by laparoscopic unipolar coagulation in 54% of the patients, by the Pomeroy technique in 28%, by fimbriectomy in 8%, by the Irving operation in 5%, and by clips or rings in 4%. In the group with no minimum follow-up period, 50% had intrauterine pregnancies and 5% had ectopic gestations. Eighty-nine patients had at least 12 months of follow-up after reversal surgery. This group is studied in detail. Factors affecting the pregnancy rate were length of tube, type of sterilization performed, anastomotic site, and availability of both tubes for reconstruction. Age, parity, and interval from sterilization to reversal surgery did not affect the pregnancy rate. Fifty percent of the intrauterine pregnancies were conceived within 6 months of reversal surgery.

[Surgical sterilization: 10 years' experience]. / Esterilización quirúrgica: experiencia en 10 años.

PIP: A sample of 1003 records of surgical sterilizations was studied from among the 9400 performed between July 1972-June 1982 at a university hospital in Nuevo Leon, Mexico. 12 patients were aged 15-19, 104 were 20-24, 244 were 25-29, 291 were 30-34, 267 were 35-39, and 85 were 40-45. Not all patients met the recommended conditions of being at least 25 years old and/or having at least 3 pregnancies. 11.6% of the patients were sterilized because of psychiatric problems, multiparity, 2 previous cesarean sections or on request of the spouse. 95.5% of the women were married, 2.1% were single, 1.6% lived in free union and .8% were widowed. 14.0% were illiterate, 57.7% had incomplete primary educations, 19.3% had completed primary school, 2.5% had incomplete secondary or technical schooling, and .3% had professional studies. 27 women had had 0-2 pregnancies, 336 had 3-5, 336 had 6-8, 198 had 9-11, and 106 had 12 or more. The maximum number of pregnancies was 20 and the average was 7.1/woman. 6 women had preoperative hemoglobin levels of 6.0 g or less, 12 had 7.0 g, 44 had 8.0, 119 had 9.0 g, 756 had 10.0, and 566 had 11.0 g or higher. Transfusions were given to all women with less than the minimum level of 10.0 g. 460 of the operations were postpartum, 334 were transcesarean, and 209 were interval procedures. 696 operations were done by the Pomeroy method, 52 by modified Pomeroy, 27 by fimbriectomy, 16 by salpingectomy, and 2 by the Uchida method. Among laparoscopic methods, 82 were done by cauterization and 128 with Yoon rings. 392 postpartum and 286 transcesarean operations were performed using the Pomeroy technique, while 82 interval sterilizations were done using cauterization and 107 using Yoon rings. Epidural anesthesia was used in 457 postpartum and 325 transcesarean procedures, while general anesthesia was used in 175 interval sterilization. There were few transoperative complications. There were 2 cases of failure to achieve salpingoclasy, 4 cases of hemorrhage, 1 case of burning of the visceral wall, 1 case of anesthetic accident, and 12 cases of other complications. Among postoperative complications there were 15 cases of abdominal pain, 1 each of fever and infection, and 1 of other complication. There was 1 pregnancy among the 1003 cases. All the procedures were performed by physicians in training.^ieng

[Changes in menstrual pattern following tubal ligation]. / Alteraciones del patrón menstrual, consecutivas a ligadura tubaria.

PIP: 50 women undergoing tubal sterilization by the modified Pomeroy technique at a hospital in Toluca, Mexico, were selected at random and followed for 6 months postoperative to detect changes in menstrual patterns. The women had normal menstrual histories and had not used contraceptive medications for at least 3 months prior to operation. Analgesia was provided by peridural block with 2% lidocaine. There were 45 cases of interval and 5 of immediate postpartum sterilization. The women ranged in age from 25 to 44 years and averaged 34.5.16 women, or 32%, had altered menstrual patterns. There were 12 cases of hypermenorrhea and 1 each of oligomenorrhea, polymenorrhea, amenorrhea, and proiomenorrhea. Age at menarche, parity, and obstetric history were unrelated to menstrual changes. Changes in menstrual patterns after surgical tubal occlusion have been attributed to damage in the uterine and ovarian blood vessels leading to reduced blood supply and ultimately to abnormal maturation of ovarian follicles and hormonal changes. Psychogenic factors may play a role. The extent of surgical damage after various techniques of tubal occlusion and the materials used for suturing should be assessed as possible sources of local or regional inflammation that could have repercussions in blood perfusion and nervous function.^ieng

Factors influencing the success of microsurgical tuboplasty for sterilization reversal.

A series of microsurgical sterilization reversal procedures has been analysed. It demonstrates that better pregnancy rates are achieved where mechanical sterilization techniques have resulted in only short lengths of tubal destruction. Isthmo-isthmic anastomoses have the most favourable outcome.

PIP: This study analyzed a series of 147 microsurgical tuboplasties performed for purposes of sterilization reversal. 87 (59%) of the women achieved at least 1 viable uterine pregnancy, 5 (3%) experienced an ectopic pregnancy, and 6 (4%) had a spontaneous abortion. Over 75% of the successful pregnancies in the series were conceived within 1 year of sterilization reversal. Sterilization techniques represented in this series included Pomeroy (71 cases), diathermy (44), ring (18), clip (7), and fimbriectomy (7). The highest success rates were associated with techniques involving the Hulka clip (86%) or the Fallope ring (78%). Reversals from the Pomeroy (56%) and tubal diathermy (59%) techniques less frequently resulted in viable pregnancies. Previous fimbriectomy procedures were successfully reversed in only 1 case (14%). Isthmo-isthmic anastomosis resulted in a viable pregnancy in 83% of cases compared to 57% for amp-isthmic and 55% for amp-cornual anastomoses. 102 (69%) of the tuboplasties were bilateral, and 66 (65%) of these procedures were successful compared to 47% of the unilateral procedures. Tube lengths of less than 4 cm were associated with somewhat depressed pregnancy rates. These results highlight the significance for the type of sterilization procedure on the prospects for pregnancy following reversal sutgery. Mechanical procedures that produce minimal damage to the isthmus of the tube are the most favorable.

[Sequelae of tubal ligation]. / Secuelas de la ligadura tubaria.

PIP: A literature review was undertaken of clinical stuides to determine the frequency of menstrual alterations or various psychosocial effects after surgical tubal sterilization. The most frequently mentioned symptoms following bilateral salpingocalsy or salpingectomy are increased menstrual blood loss, dysmenorrhea, dispareunia, pelvic pain, oligemenorrhea, polymenorrhea, and preclimacteric syndrome in some cases. Uribe and colleagues attributed the high frequency of abdominal pain in tubal occlusions achieved with mechanical devices such as rings to the compression pain produced by uncut nerve edings, which do not occur with electrocoagulation or the Pomeroy technique. Alderman and colleagues found that only 6.5% of their patients experienced increased menstrual flow after sterilization, but Rioux found confirmation of menstrual changes to be difficlut and Chamberlain reported change in 2.6-51% of patients, perhaps related to previous use of contraceptives. Radwanska and colleagues found that patients sterilized by electrocoagulation or tubal ligation had a lower average level of serum progesterone in the midluteal cycle phase, 9.4 +or- 4.7 ng/ml compared to 17.4 +or- 7.1 ng/ml for controls. Donnez found that patients sterilized by electrofulguration had an average of 8.5 +or- 6 ng/ml of progesterone in the midluteal phase compared to 15.4 +or- 6.3 ng/ml for those sterilized using Hulka clips. The largest proportion of women with menstrual alterations or pain were younger, lower parity women who were sterilized for medical reasons. Menstrual changes and pelvic symptoms following sterilization are subjective and difficult to evaluate. Some authors cite the rarity of longterm sequelae of sterilization, but others used radioimmunoassay techniques to demonstrate changes in serum progesterone levels that may be linked to alterations in function of the ovaries or corpus luteum following sterilization. Other authors believe that most negative sequelae could be minimized or eliminated with better patient selection and counseling.^ieng