Hysterosalpingography in the investigation of women requesting reversal of sterilization. Should it play a role?

OBJECTIVE: To evaluate the role of hysterosalpingography (HSG) in the investigation of women requesting reversal of sterilization (ROS). STUDY DESIGN: A prospective, cohort study at a university-affiliated, tertiary fertility clinic. All women proceeding to surgery were investigated with HSG in addition to other routine screening. Findings from HSG were tabulated to document the prevalence of abnormalities and correlated with histologic findings in resected tubal segments. RESULTS: One hundred sixteen women of 166 referred for ROS underwent HSG during the initial evaluation. HSG depicted abnormal tubal images in only 2 cases (1.7%) and abnormal uterine images in 15 (12.9%) cases. In the cases of abnormal tubal findings, there was no association with histologic findings. The specificity of HSG as a diagnostic screening tool was 90%; however, the small number of cases with abnormal histology prevented calculation of an accurate estimate of sensitivity of HSG as an investigative tool before ROS. A less invasive method of imaging the uterus, such as a vaginal ultrasound, may provide more valuable information in evaluating the future fertility outcome in these women. CONCLUSION: The prevalence of abnormalities of the proximal oviductal segment identified by HSG is too low to warrant the routine use of HSG as a diagnostic tool.

Follow-up of women seeking sterilization reversal: a Brazilian experience.

OBJECTIVE: To analyze the follow-up of a cohort of women who requested reversal of surgical sterilization. METHODS: This retrospective study was carried out at the State University of Campinas, Brazil. A cohort of 394 women who requested sterilization reversal was followed up for one year after reversal surgery. The analysis includes the percentage of women who completed the steps between the initial consultation up to one year after reversal surgery. RESULTS: After an initial consultation, 55.1% of the patients decided not to continue with the procedures. Of the patients who did undergo laparoscopy (n = 177), 48.6% had no possibility of a successful surgical reversal because the Fallopian tubes were in very poor condition. Only 17.5% of the initial patients requesting reversal ultimately underwent surgery and 3.3% became pregnant. CONCLUSIONS: The analysis of regret about surgical sterilization should include not only women who undergo surgery but also women requesting surgery. Better patient selection and counseling prior to sterilization are necessary in order to prevent increasing rates of sterilization regret in Brazil.

Male sterilization.

This review of recent information and advances in the area of male sterilization deals with recent epidemiologic studies that discuss potential ill effects hypothesized to be a result of vasectomy, including carcinoma of the prostate and carcinoma of the testicle. Rebuttals to these hypotheses are presented. Recent advances in techniques of vasectomy including the "no-scalpel" vasectomy technique and open-ended vasectomy are presented, including the rationale for their use. A good deal of attention is given to postvasectomy follow-up, particularly the use of the technique of measuring numbers of ejaculations following vasectomy rather than the period of time afterward to determine when a man is sterile. The final two sections deal with complications of vasectomy and the most recent percentages on reversing vasectomy with particular reference to return of sperm to the ejaculate and pregnancy rates.

PIP: Between 250,000 and 300,000 US men undergo vasectomy each year. The Association for Voluntary Surgical Contraception has performed almost 400,000 vasectomies worldwide since 1982. 2 hospital-based case control studies indicate a 1.7-5 fold increased risk of prostate cancer in vasectomized patients, but other studies do not find this association. Besides, there is no biologic basis for such an association. A theoretical relationship does exist between testicular cancer and vasectomy, however, since testicular biopsy studies reveal abnormalities, perhaps secondary to back pressure. No epidemiologic studies have yet found such a link, though. In China, some 8 million men have undergone the no-scalpel vasectomy developed in the 1970s. This technique has fewer complications than the traditional technique (e.g., a hematoma rate of only .08%). Indeed, hematomas are the most common complication. Other complications include epididymitis, congested epididymis, and sperm granuloma. The open-ended vasectomy (proximal testicular end of vas left open and closure of the distal end) reduces postoperative testicular and epididymal discomfort and increases the likelihood of vas reversal (1 surgeon reports a success rate of 100%). Regardless of the vasectomy technique, vas reanastomosis is more likely to be successful if performed within 5 years after the vasectomy (e.g., 1 study reported a pregnancy rate of 52% for reanastomosis within 5 years vs. 30% for 5 years; p .02). Physicians recommend a postvasectomy semen analysis after 20 ejaculations to determine if azoospermia has been achieved. If not, another analysis is needed after 10 more postvasectomy ejaculations. If motile sperm still exist, the vasectomy has failed. Yet, many men (36-45% in the US) do not return for analysis. Return visits are often difficult, impractical, and embarrassing for men, so physicians should suggest patients use condoms until after they have achieved a predetermined number of ejaculations to ensure protection against pregnancy.

Ovum recovery after microsurgical reanastomosis of the rabbit oviduct.

Causes for failure of pregnancy after tubal reconstructive surgery are incompletely understood. The impact of microsurgical resection reanastomosis on ovum recovery was studied in the rabbit oviduct. One hundred sixty rabbits were divided into three groups: one experimental group in which a resection reanastomosis was made in the ampullar or isthmic tubal segment, respectively, and two control groups. After mating, ovum recovery was evaluated. In ampullary operated oviducts the ovum recovery rate was significantly lower compared with recovery rates in isthmically operated and in control oviducts. Furthermore, in ampullary operated oviducts peritoneal transmigration of ova was frequently observed. Disturbances in ovum pickup from the ovarian surface or the peritoneal cavity seem to be responsible for the decrease in recovery rate found in the ampullary operated oviducts.