Abstract

PIP: To meet the demand of patients who regret their tubal sterilization, microsurgical techniques have been developed to reverse the process. This discussion reappraises the role of such techniques and their efficacy. Of all the tubal sterilization methods, those with the least amount of tubal destruction and with preservation of fimbriae provide the best chance for a reversal. The chances for successful reversal seem to be better in patients who undergo the Pomeroy method of sterilization or in those in whom the tubal occlusion is achieved by the use of clips or rings. Tubal fulguration by laparoscopy offers less promise for reversal, especially when the multiple burn technique is used, because of the excessive tubal destruction caused. Tubal uterine implantations consist of the implantation of either the isthmic or the ampullary segment of the tube into the uterus. The sterilization best suited for this method of reversal is one in which the portion of the tube next to the uterus has been destroyed, i.e., when a cornual anastomosis is not feasible. This is frequently the case following tubal fulguration. Tubal anastomisis can be divided in 6 types according to the segment involved: intramural-isthmic; intramural-ampullary; isthmic-isthmic; isthmic-ampullary; ampullary-ampullary; and ampullary-infundibular. Technically the easiest ones to reverse are those in which the proximal and distal lumina are of relatively equal size. The best results are generally obtained with anastomisis between 2 tubal segments without excessive caliber disparity. Salpingoneostomy involves the creation of a new tubal osteum. The tubal sterilization most appropriate for reversal with a salpingoneostomy is a fimbriectomy. Depending upon whether the latter is distal or medial, the salpingoneostomy can be terminal, midampullary, or isthmic. Patients in whom reversal of sterilization is contraindicated are identified. The reversal of sterilization by microsurgery involves gentle handling of tissue, meticulous hemostasis, the use of delicate instruments and fine sutures, careful dissection, accurate tissue approximation, and magnification techniques. A comparative analysis of clinical results revealed that the results achieved with the microscopic technique for the reversal of sterilization appeared to be significantly better than with a gross technique. Tubal anastomisis appears to be more often successful than implantation or salpingeoneostomy. Until more valid statistical data are collected, it can be stated that microsurgery offers a potential increase in the intrauterine pregnancy rate when used to reverse tubal sterilization. The cost and the increased risk of ectopic pregnancy associated with reanastomosis obligate the gynecologist to offer appropriate counseling to patients requesting sterilization.