Laparoscopic Essure® Device Removal by En Bloc Salpingectomy-Cornuectomy with Intraoperative X-Ray Checking: A Retrospective Cohort Study.

STUDY OBJECTIVE: To evaluate the feasibility, efficacy, and morbidity of Essure® device removal via laparoscopic en bloc salpingectomy-cornuectomy resection (LSC) and the utility of confirmation of complete removal with an intraoperative X-ray of the removed specimen (IX-S). DESIGN: Retrospective observational cohort study. SETTING: Academic hospitals of La Conception, Marseille, and Arnaud-de-Villeneuve, Montpellier, France. PATIENTS: Women who were not seeking future fertility seeking Essure® device removal by salpingectomy, between February 2017 and August 2018. INTERVENTIONS: All women underwent LSC. An IX-S was performed to confirm complete Essure® device removal. In the case of an unsatisfactory IX-S, an intraoperative pelvic X-ray control of the patient (IX-P) was performed. If IX-P diagnosed residual Essure® fragments, an additional resection was performed, and the removed tissue was checked by IX-S. MEASUREMENTS AND MAIN RESULTS: We included 72 women, and a total of 140 Essure® devices were removed. The IX-S confirmed complete Essure® device removal in 131 of 140 cases (93.6%) in 63 of 72 women (87.5%). Out of the 9 women with unsatisfactory IX-S, 6 had no residual Essure® fragments at IX-P, and Essure® device removal was considered complete. Three women had a persistent Essure® fragment at IX-P: an additional resection allowed complete removal in 2 cases and resulted in failure in 1 of 140 case (0.7%). There were 2 of 72 women (2.8%) intraoperative complications and 4 of 72 women (5.6%) postoperative grade 1 complications according to the Clavien-Dindo classification. CONCLUSION: Essure® device removal by LSC appears to be an effective and safe procedure. IX-S is a useful method to evaluate whether the removal of Essure® device is complete during an LSC procedure.

Open epididymal spermatozoa aspiration for obstructive azoospermia.

In men suffering from obstructive azoospermia (OA), surgical sperm retrieval (SR) can be performed for use with intracytoplasmic sperm injection (ICSI). Several techniques of surgical SR exist, with various results. In our facility, we have developed the open epididymal spermatozoa aspiration (OESA) procedure. The aim of this study was to report on the sperm retrieval rate (SRR), reproductive outcome and neonatal outcome of OESA followed by ICSI. In addition, we have investigated possible predictors of successful SR and clinical pregnancy. A total of 231 men who were treated with OESA were included in this retrospective analysis, together with their female partners. We found an overall SRR of 76.6%. Serum FSH was a significant negative predictor of successful SR (odds ratio 0.87; 95% CI 0.78-0.98; p = 0.021). Overall cumulative pregnancy rate was 50.8%. Higher age (odds ratio 0.90; p < 0.001) and frozen vs. fresh embryo transfer (odds ratio 0.56; p = 0.004) were negatively associated with clinical pregnancy in multivariable analysis. Reproductive and neonatal outcomes did not differ according to obstruction cause. We conclude that OESA is a reliable and safe method for surgical SR in men suffering from OA.

Sperm agglutination: Prevalence and contributory factors.

Agglutination is a finding noted in semen analyses (SAs) that often causes confusion as to its significance. While some have attributed agglutination to antisperm antibodies (ASAs), there are other causes as well, such as genital tract infection and ascorbic acid deficiency. Additionally, it is known that patients with ASAs often have risk factors such as a history of scrotal trauma or surgery. Therefore, we sought to determine the prevalence of agglutination in our patient population and correlate it with these risk factors, regardless of the presence/absence of ASAs. A retrospective study was conducted on the SAs of men seen at a single academic Reproductive Center. Of the 1,095 SAs identified, 133 (12.1%) patients experienced agglutination (61.7% scant, 21.8% moderate and 16.5% excessive). Of patients who underwent multiple SAs, 24 (12.2%) showed variability. Furthermore, patients who underwent scrotal surgery carried 3.4 times the risk of agglutination (X2 p < 0.01) and 5.5 times the risk of variability (X2 p < 0.01) as compared to those patients without a history significant for scrotal surgery. Agglutination is a relatively common finding in men presenting to a reproductive clinic with little intrapatient variability. Scrotal surgery confers a higher risk of agglutination and variability.

Management of long-term and reversible hysteroscopic sterilization: a novel device with nickel-titanium shape memory alloy.

BACKGROUND: Female sterilization is the second most commonly used method of contraception in the United States. Female sterilization can now be performed through laparoscopic, abdominal, or hysteroscopic approaches. The hysteroscopic sterilization may be a safer option than sterilization through laparoscopy or laparotomy because it avoids invading the abdominal cavity and undergoing general anaesthesia. Hysteroscopic sterilization mainly includes chemical agents and mechanical devices. Common issues related to the toxicity of the chemical agents used have raised concerns regarding this kind of contraception. The difficulty of the transcervical insertion of such mechanical devices into the fallopian tubes has increased the high incidence of device displacement or dislodgment. At present, Essure® is the only commercially available hysteroscopic sterilization device being used clinically. The system is irreversible and is not effective immediately. PRESENTATION OF THE HYPOTHESIS: Our new hysteroscopic sterility system consists of nickel-titanium (NiTi) shape memory alloy and a waterproof membrane. The NiTi alloy is covered with two coatings to avoid toxic Ni release and to prevent stimulation of epithelial tissue growth around the oviducts. Because of the shape memory effect of the NiTi alloy, the device works like an umbrella: it stays collapsed at low temperature before placement and opens by the force of shape memory activated by the body temperature after it is inserted hysteroscopically into the interstitial tubal lumen. The rim of the open device will incise into interstitial myometrium during the process of unfolding. Once the device is fixed, it blocks the tube completely. When the patient no longer wishes for sterilization, the device can be closed by perfusing liquid with low temperature into the uterine cavity, followed by prospective hysteroscopic removal. After the device removal, the fallopian tube will revert to its physiological functions. TESTING THE HYPOTHESIS: Currently, experimental and clinical studies are needed to attest the safety, efficiency and reversibility of the novel sterilization device. IMPLICATIONS OF THE HYPOTHESIS: If our hypothesis is confirmed, appropriate and reversible contraceptive can be achieved with the device we have designed, which may have significant repercussions for numerous women worldwide.

Novel reversible permanent contraception: an animal experiment of embedding contraceptive surgery in the fimbriated extremity of the fallopian.

AIM: According to female pelvic anatomical characteristics, we designed a novel reversible permanent contraception: embedding contraceptive surgery in the fimbriated extremity of the fallopian. This study involves embedding the oviduct of New Zealand rabbits into the peritoneum, and assesses contraceptive effect, morphological changes and recoverability. METHODS: Thirty New Zealand rabbits were divided into three groups: embedding in the fimbriated extremity of the fallopian group (A group); polyethylene film in the fimbriated extremity of the fallopian group (B group); and control (C group). Surgery was performed in each group, respectively. Contraceptive efficacy, morphological changes and recoverability were noted. RESULTS: As for contraceptive effect, mating experiences were successful. After 3 months, there were no pregnant rabbits in group A and B, while in group C all samples were pregnant. Regarding recoverability, after belly operation, 10 rabbits in group A showed dropsy in the bilateral oviducts. Tissue adhesion could be found in the fimbriated extremity of the fallopian with a large range of damage. All samples in group B also had dropsy, but only two of them had unilateral slight adhesions in the fimbriated extremity of the fallopian, while others had no pathological changes. After being released from the oviduct embedding, five rabbits in group A became pregnant and nine in group B. CONCLUSION: Embedding contraceptive surgery in the fimbriated extremity of the fallopian after being covered by polyethylene film is reliable and safe. Releasing the embedding may cause minor injury. Although there is a problem of hydrosalpinx, the pregnancy rate is high.

The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures.

PURPOSE: The incidence of ectopic pregnancy (EP) in the general population is 2%, whereas the EP rate following assisted reproductive technologies (ART) is between 2.1 and 11%. EP is also an adverse effect of tubal surgery with incidences up to 40% depending on the type, location, and severity of tubal disease and the surgical procedure. METHODS: This paper looks at the incidence of EP following tubal reconstructive microsurgery, analyzes risk factors for EP following own 1,295 ART cycles and looks on the incidence of EP in 128,314 pregnancies following ART according to the presence or absence of tubal infertility using data from the German IVF Registry (DIR). RESULTS: In our clinic, the EP rate following resterilization was 6.7%. In the presence of acquired tubal disease, the EP rate following adhesiolysis, salpingostomy, salpingoneostomy, fimbrioplasty, and anastomosis was 7.9%. The EP rate following ART in our clinic was 5.6%. Previous abdominal surgeries, microsurgical procedures, hydro-/sactosalpinges, salpingitis, salpingitis isthmica nodosa, and periadnexal adhesions showed a significant positive correlation with EP as outcome. Data of DIR demonstrate a significantly increased incidence of EP in the presence of tubal pathology. The highest EP rate related to all clinical pregnancies was 4.5% (95% CI 3.0-6.0) in smoking women <30 years with tubal pathology following IVF. CONCLUSIONS: In the presence of tubal infertility, the incidence of EP following ART and tubal microsurgery are approximately comparable with each other and higher than in women without tubal infertility. The success of infertility surgery depends on a careful selection of appropriate patients.

Organ-preserving and reconstructive microsurgery of the fallopian tubes in tubal infertility: still an alternative to in vitro fertilization (IVF).

Tubal infertility mostly results from infections. Conception only is possible through complex treatments (in vitro fertilization or surgery). Success cannot be guaranteed, even after repeated treatments. Unfortunately, many couples are not informed about the prospect for success of tubal reconstruction. Problems of in vitro fertilization are low pregnancy and birth rates of 28.4% and <20% respectively (Germany) and the high number of multiple pregnancies (21%). In this retrospective study 462 women with acquired tubal infertility and further 127 women after previous sterilization underwent microsurgical treatment (microsurgical adhesiolysis, anastomosis, fimbrioplasty, salpingostomy, and refertilization due to former sterilization). The main outcome measures are the pregnancy and birth rates following the microsurgical procedure. Pregnancy and birth rates of 43.4% and 29.2%, respectively, were higher than the outcomes post-single in vitro fertilization (abortion: 6.4%, extrauterine pregnancy: 7.9%). When reversal of sterilization was performed, pregnancy and birth rates were higher at 73% and 50.6%, respectively (abortion: 15.7%, extrauterine pregnancy: 6.7%). The advantages of reconstructive microsurgery over in vitro fertilization include the ideally permanent restoration of woman's ability to conceive naturally (repeated pregnancies are possible without further therapy), a high postoperative birth rate overall, and avoidance of multiple births. It is advisable to inform the patient about the objective possibility of reconstructive tubal surgery.

Transvaginal natural orifice transluminal endoscopic surgery tubal reanastomosis: a novel route for tubal surgery.

OBJECTIVE: To demonstrate how a transvaginal natural orifice transluminal endoscopic surgery (NOTES) tubal reanastomosis is a novel route for tubal surgery. The surgical technique is a combination of traditional vaginal surgery with single-site surgical skills. DESIGN: The surgical technique is explained in a stepwise fashion with the use of surgical video footage. The video uses a surgical case to demonstrate the specific techniques necessary to perform a NOTES tubal reanastomosis. SETTING: Teaching university. PATIENT(S): A 42-year-old female G2P2 with a history of tubal ligation 11 years before presentation requesting a tubal recanalization. INTERVENTION(S): Transvaginal NOTES tubal reanastomosis was initiated with a posterior colpotomy. A single-site gelport was placed. The fallopian tubes were hydrodissected, the blocked portion of each tube was removed, an epidural catheter was threaded through each lumen, and the two remaining segments of each tube were sutured together in an end-to-end fashion using single-site suturing skills. MAIN OUTCOME MEASURE(S): Transvaginal NOTES tubal reanastomosis as an alternative route for tubal reanastomosis. RESULT(S): The bilateral fallopian tubes were recanalized with bilateral tubal patency. This was confirmed 8 weeks postoperatively with a three-dimensional sonohystogram, which showed patency of the bilateral fallopian tubes. CONCLUSION(S): The current preferred technique for reversal of a tubal sterilization is to perform a minimally invasive surgery with an end-to-end anastomosis. This gives the patient a 60%-90% intrauterine pregnancy rate postoperatively. NOTES has the benefits of a fast recovery, no abdominal incisional pain, and an extremely cosmetic outcome. Current research has shown a 0%-3.1% range for the risk of pelvic infection in transvaginal NOTES if prophylactic antibiotics are administered during the surgery. The NOTES tubal reanastomosis combines the traditional vaginal surgery technique of creating a posterior colpotomy with single-site surgical skills like suturing and knot tying. The surgery is completed through a single transvaginal port without an abdominal incision. In the hands of a skilled minimally invasive surgeon, transvaginal NOTES tubal reanastomosis is a feasible and alternative route for this procedure.

Vasovasostomy in the rat. Improved technique using absorbable microsuture (polyglycolic acid).

An improved technique for vasovasostomy in the rat is presented. To eliminate the suture crowds that could cause obstruction of the vasal lumen, one deep raw suture technique had been employed using polyglycolic acid (Dexon) microsuture. A total of 62 vasal anastomoses in 48 male Lewis rats was performed, and follow-up to twelve months found no disruption or constriction at the anastomoses. Despite occasional sperm granuloma formation at the anastomotic sites, all anastomoses demonstrated patency. Dexon appears to be suitable for genitourinary tract surgery, at least, in the rat.

Microsurgery for vasectomy reversal and vasoepididymostomy.

Accurate microsurgical techniques developed by us have allowed a considerable improvement in success rate for vasectomy reversal, and a better understanding of the pathophysiology of obstruction. This has permitted us also to treat pathologic obstructive azoospermia more effectively.

An unusual complication of tubal anastomosis.

OBJECTIVE: To report an unusual complication associated with the use of a long-term intrafallopian stent during microsurgical tubal anastomosis. DESIGN: Case report. SETTING: Tertiary academic center. PATIENT(S): A 36-year-old woman in whom an intrafallopian stent used during a sterilization reversal procedure could not be transcervically retrieved in the office. INTERVENTION(S): Hysteroscopic evaluation for removal of intrafallopian stent, followed by operative laparoscopy for postoperative abdominal pain. MAIN OUTCOME MEASURE(S): Patient symptoms, potential for morbidity, and review of the literature. RESULT(S): Hysteroscopic view of the uterine cavity failed to identify the intrafallopian stent. Laporoscopic evaluation of postoperative abdominal pain revealed significant formation of pelvic and abdominal adhesions. The 2-0 nylon suture used as an intrafallopian stent was seen sitting freely on top of the liver serosa. Adhesiolysis and successful retrieval of the stent resolved the patient's symptoms. CONCLUSION(S): To our knowledge, this is the first report describing complete dislodgment and cephalad migration of an intrafallopian stent. Patient morbidity and health care costs may increase when long-term stents are used for sterilization reversal.

Microscopic vasectomy reversal.

More than 300 patients undergoing microscopic vasovasostomy have been carefully studied in an effort to determine the factors which affect the recovery of fertility after an accurate microscopic reanastomosis. The over-all pregnancy rate in an unselected group of early patients was 71%. Recovery of fertility correlated with the return of normal sperm counts and with the quality of seminal fluid in the vas deferens on the testicular side of the obstruction at the time of vasovasostomy. The three most important factors influencing return of fertility after vasovasostomy are (1) a meticulous microscopic technique for reconnection, (2) the duration of time the vas deferens has been obstructed, and (3) the presence of absence of a sperm granuloma at the site of the vasectomy, venting the long-term pressure buildup which otherwise would occur. The presence of a sperm granuloma at the vasectomy site generally ensured the presence of good quality sperm in the vas fluid at the time of vasovasostomy and the recovery of a good sperm count postoperatively. If all three of these factors are favorable, vasectomy should be reversible for most patients.

Abnormalities of sperm morphology in cases of persistent infertility after vasectomy reversal.

PIP: Persistent infertility after vasectomy reversal by vasovasostomy may be due to irreversible changes in epididymal physiology, producing morphologic abnormalities of the sperm tail. Specimens from 29 men with persistent infertility following vasectomy reversal were analyzed and sperm motility and morphology were evaluated. the percentage of motile sperm was below normal in 23 specimens. Swimming speed evaluation on 20 specimens showed only 4 were below the normal range. In 19 of the 29 specimens, 10% or more of the sperm cells examined were characterized by a normal head and a coiled or shortened tail. Within this group, the percentage of sperm with tail abnormalities ranged from 2-64%, with a mean of 18.1%. The appearance of sperm tail abnormalities in conjunction with normal or high sperm concentrations suggests a disturbance of epididymal physiology. The epididymal environment is required for the final maturation of spermatazoa and the acquisition of normal motility and fertilizing ability. The study results suggest that these epididymal functions may be impaired in some men after vasectomy. A case report of a 32 year old man who had a vasectomy 7 years prior to referral to the evaluation group, and a successful vasovasostomy 2 years prior, revealed only 20% of the sperm evaluated in the initial specimen had the normal head and tail shape. His semen volume was 3.5 ml with a sperm concentration of 250 million/ml. 25% of the sperm were motile. Reexamination of the semen 8 times during the next year showed no significant changes. The cervical mucus penetration test showed no abnormalities of the sperm-cervical mucus interaction. When the motile sperm were spearated from the immotile cells and incubated with zona-free hamster eggs, all of the eggs were penetrated. Attempts were unsuccessful to isolate sufficient numbers of motile cells for artificial insemination, however, a normal pregnancy was conceived 1 year after the initial evaluation without additional therapy. One other man from the group also produced a pregnancy. It is suggested that the morphologic abnormalities may not confer sterility on the affected individual even when present in the majority of sperm cells, as indicated by the ability of sperm with normal tails to fuse with zona-free hamster eggs in vitro.^ieng

Reversal of female sterilisation: a comparative study.

In 80 women who had reversal of sterilisation, a study was made of their clinical features at the time of sterilisation and of the factors related to successful outcome. Compared with controls at the time of sterilisation, the women requesting reversal were younger, of lower social class and of higher parity; in addition they were more likely to have an unstable relationship and to have been sterilised following a recent pregnancy. After reversal, intrauterine pregnancy occurred in 26/80 (32.5%) and ectopic pregnancy in 6/80 (7.5%), the majority of successful pregnancies occurring in younger women within one year of reversal following a non-destructive method of tubal occlusion. There was no evidence that techniques of management, including the use of an operating microscope, significantly influenced outcome, and controlled trials will be required to establish their efficacy.

PIP: In 80 women who had reversal of sterilization, a study was made of their clinical features at the time of sterilization and of the factors related to successful outcome. Compared with controls at the time of sterilization, the women requesting reversal were younger, of lower social class and of higher parity; in addition they were more likely to have an unstable relationship and to have been sterilized following a recent pregnancy. Only 24% were still in their original marriage. Most of these gave regret as the reason for their request, while the rest had lost children. The remaining women wished reversal because of a change of partner; 2/5 had remarried, while 3/5 were single, widowed, separated or divorced, but cohabiting. It is clear that sterilization at delivery may be in response to severe social pressure, but it may not always be in the patients' longterm interests to yield to such pressure. After reversal, intrauterine pregnancy occurred in 32.5% and ectopic pregnancy in 7.5%, the majority of successful pregnancies occurring in younger women within 1 year of reversal following a non-destructive method of tubal occlusion. There was no evidence that techniques of management, including the use of an operating microscope, significantly influenced outcome; controlled trials will be required to establish their efficacy.

Fertility following reversal of male and female sterilization.

It is estimated that 60% of Australian couples will opt for sterilization as a method of birth control. Approximately 0.5 to 1% of all sterilized males and females will request reversal. With tubal occlusion, it appears that the method used to produce occlusion, the occlusion site, the length of viable tube remaining and the time between sterilization and reversal appear to be predictive factors in producing intrauterine pregnancy. With the increasing tendency for sterilization to be performed in younger women, surgeons should consider performing surgery only on the isthmus of the tube, preserving as much undamaged tube as possible and using methods of occlusion other than diathermy to ensure adequate tubal occlusion and yet maintain optimum conditions should reversal be required. Successful pregnancy following vasovasostomy appears to be related primarily to length of time elapsed following vasectomy and to the skill of the surgeon in the use of microsurgical techniques, possibly aided by preservation of nerve supply to the vas. It is doubtful whether the presence of sperm antibodies in serum or semen will affect the return of fertility in most individuals, but further research is required to clarify this.

Microsurgical reversal of female mechanical sterilization techniques.

This study presents the patient characteristics, the reason for requesting a reversal operation, the surgical technique and pregnancy rates after a microsurgical reanastomosis following a mechanical (ring or clip) method of sterilization in 55 women. A corrected intrauterine pregnancy rate of 90% was obtained. Ectopic pregnancy occurred in 7% of the patients. Human female sterilization presently has a very high probability of being reversible on the condition that a careful mechanical sterilization has been performed.

PIP: Tubal sterilization has become the most common contraceptive method in women over 30, but an estimated 1% request reversal. Ring or clip tubal occlusion can be reversed microsurgically by removing the device and reanastomosing the fallopian tubes, usually at the isthmic segment. Of 55 patients whose tubal occlusion was surgically reversed, 90% became pregnant, and 33 had at least 1 child. The average time between reversal and conception was 6 months. The most serious risk after sterilization reversal is ectopic pregnancy (7%-21%). Spontaneous abortion rates are also high, but this may be due to the age of the women rather than to adverse effects of the surgery. Ring or clip sterilization has only a slightly higher failure rate than electrocoagulation, but it has the advantage of being successfully reversible.

Ectopic pregnancy in a distal tubal remnant.

Ectopic pregnancy is a well-recognized complication of tubal reanastomosis (Young PE, Egan JE, Barlow JJ: Reconstructive surgery for infertility at the Boston Hospital for Women. Am J Obstet Gynecol 108: 1092, 1970 and Hodari AA, Vibhasiri A, Isaac AY: Reconstructive tubal surgery for midtubal obstruction. Fertil Steril 28: 620, 1977). We describe here, however, a case of tubal pregnancy occurring in a tubal remnant on the opposite side to a successful tubocornual reanastomosis.

[Relationship between microsurgical tubal reversal and ectopic pregnancy].

OBJECTIVE: To study the correlation between microsurgical tubal reversal after tubal sterilization and ectopic pregnancy. METHODS: 1029 women who underwent microsurgical tubal reversal were followed up. The causes of ectopic pregnancy were analysed and discussed. RESULTS: 960 intrauterine pregnanciess and 12 ectopic pregnancies occurred. The 12 ectopic pregnancies were all tubal ones, among which 2 had intrauterine pregnancies. The rate of ectopic pregnancy in the 1029 women was 1.17%, and in the pregnant cases was 1.23%. The ratio of intrauterine pregnancy to ectopic pregnancy was 1:80. The rates of ectopic pregnancy in the 1st, 2nd year and 2 years later after tubal reversal were not significantly different respectively among the tubal reversal and among the pregnant cases. The rates of ectopic pregnancy in the 1st and 2nd 6 months after tubal reversal were not statistically different. The early tubal hydrapertubation could only increase the chance of ectopic pregnancy. The sterilization method, reversal mode, and interval between sterilization and reversal were not related to the ectopic pegnancy. CONCLUSION: When the lesion in the sterilized position is completely removed, the sutures being through the tubal mucosa and the early tubal hydrapertubation not carried out, the chance of ectopic pregnancy can not be increased after tubal reversal. The contraception 6 months after tubal reversal is not related to ectopic pregnancy.

Robotics in reproductive surgery: strengths and limitations.

Minimally invasive surgical techniques are becoming increasingly common in gynecologic surgery. However, traditional laparoscopy can be challenging. A robotic surgical system gives several advantages over traditional laparoscopy and has been incorporated into reproductive gynecological surgeries. The objective of this article is to review recent publications on robotically-assisted laparoscopy for reproductive surgery. Recent clinical research supports robotic surgery as resulting in less post-operative pain, shorter hospital stays, faster return to normal activities, and decreased blood loss. Reproductive outcomes appear similar to alternative approaches. Drawbacks of robotic surgery include longer operating room times, the need for specialized training, and increased cost. Larger prospective studies comparing robotic approaches with laparoscopy and conventional open surgery have been initiated and information regarding long-term outcomes after robotic surgery will be important in determining the ultimate utility of these procedures.

Microsurgical reversal of sterilisation - is this still clinically relevant today?

INTRODUCTION: Women with previous tubal sterilisation seeking fertility are faced with treatment options of reconstructive tubal surgery or in vitro fertilisation (IVF) techniques. The aim was to assess the current viability of tubal anastomosis in a local clinical practice. MATERIALS AND METHODS: A retrospective cohort review of all sterilisation reversal cases from January 1998 to January 2008. The main outcome measures included fi rst pregnancy success and live birth after surgery. Subsequent live births, ectopic pregnancies, miscarriages, duration of surgery and hospitalisation within the study period were also reported. We included cases aged less than 40 years, without any known semen abnormalities, and performed by only one operator. Cases with only unilateral reversal were excluded. RESULTS: Nineteen cases with previous Filshie clip ligation (9 laparoscopic/10 open) were reviewed. Cumulative pregnancy rates with surgery were 47.4% (<6 months), 57.9% (6 to 12 months), 68.4% (12 to 48 months) and 73.7% (>48 months). Pregnancy (77.8% vs 70.0%) and live birth rates (66.7% vs 60.0%) were similar between laparoscopy and open surgery. The mean interval to pregnancy was marginally lower via laparoscopy (11.3 vs 13.6 months). Hospitalisation stay was significantly halved (1.43 vs 3.00 days) but ectopic pregnancies were increased 3-fold (3 vs 1) with laparoscopy. Compared with IVF, the estimated average cost per delivery for laparoscopic reversal was reduced for laparoscopic reversal with no multiple pregnancies. CONCLUSION: Our results favour surgical reversal after sterilisation for patients younger than 40 years old. It avoids hyperstimulation risks and the economic burdens associated with multiple pregnancies. Where expertise is available, laparoscopic reversal should be performed.