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.

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.

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.

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.

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.

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.

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.

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.

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.

Laparoscopic microsurgical tubal reanastomosis: a preliminary study.

OBJECTIVE: To determine the effect of laparoscopic reversal of tubal sterilization on pregnancy rate. METHODS: Eight patients who underwent laparoscopic tubal reversal between March 1999 and 31 December 2001 were evaluated. RESULTS: Four of eight patients who had had laparoscopic tubal reversal became pregnant. Three have delivered; pregnancy in the fourth woman is ongoing. To date, the other four patients are still not pregnant. Two ofthese four cases have tubal patency but have not achieved pregnancy; in the other two cases, the operation was unsuccessful and tubal patency did not occur. CONCLUSION: In our preliminary study, the pregnancy rate was 50%.

The efficacy of transcervical recanalization of obstructed postoperative fallopian tubes.

The efficacy of transcervical recanalization of obstructed postoperative Fallopian tubes was evaluated in 29 patients who were referred for recanalization. Nineteen had strictures at the site of Fallopian tube reconstruction, and five had strictures, three had fistulae, and two had fistulae and strictures at the site of reversal surgery. A 0.014-inch highly flexible guidewire was passed through the obstruction into the ampullary segment, followed by a 1. 1-2.2 Fr bougie catheter to dilate the stricture. After recanalization, the distal tube was studied by selective salpingography. The method was technically successful in 17 of 19 patients with underlying inflammatory disease and resultant postoperative strictures. The tubes remained patent in 12 patients for a period of 12-48 months; three patients conceived, all delivering healthy babies. Significant disease of the distal tubes was present in seven patients. The technique succeeded in three of five patients with postoperative strictures following reversal surgery. One patient subsequently conceived and delivered a healthy baby. The technique failed in all five patients with fistulae complicating reversal surgery. Transcervical recanalization is thus recommended in the management of patients with postoperative strictures with underlying inflammatory obstruction and strictures complicating reversal surgery.

[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.

Anastomosis tubo-tubarica en el Instituto Materno Infantil de Bogotá: diez años de experiencia

Se revisan 90 historias clínicas de pacientes que consultan a la Clínica de Infertilidad del Instituto Materno Infantil de Bogotá para recanalización tubárica posterior a esterilización quirúrgica en el período del 1§ de enero de 1983 al 31 de diciembre de 1992. Se practicó la evaluación completa de la pareja para determinar la presencia de factores de infertilidad diferentes a la ligadura tubárica. El factor tuboperitoneal fue evaluado por laparoscopia previo en la gran mayoría de los casos pero omitió en 18 casos basados en los datos de la cirugía. Se realizó la anastomosis con técnica microquirúrgica, lupas con aumento de 4X para magnificación y suturas Vicryl 7-0u 8-0, irrigación con Lactato Ringer con heparina y corticoides y antibióticos. se realizaron 53 anastomosis, 41 posteriores a bandas de silastic y 12 a ligadura por técnica de Pomeroy, con una tasa global de embarazo a término del 62 por ciento, embarazo ectópico del 4 por ciento y aborto en 2 por ciento. El resultado fue mejor para las bandas que para los Pomeroy (66 por ciento vs. 50 por ciento). No se encontró diferencia para el tiempo de ligadura ni segmento anastomosado. El resultado de la anastomosis intramural itsmica ( 75 por ciento) demuestra la utilidad de las lupas aún en este segmento. La tasa de embarazo para longitud tubárica residual mayor de 6 cms. (72 por ciento) fue mejor que para longitudes de 4-6 cms. (55 por ciento). Se demuestra la utilidad de las lupas en microcirugía, la longitud tubárica residual como factor pronóstico y las tasas y tiempos de embarazo

Laparoscopic-assisted tubal anastomosis.

STUDY OBJECTIVE: To determine the length of procedure, length of hospital stay, complications, and postoperative pregnancy rates of traditional tubal anastomosis (TA) and laparoscopic-assisted TA (LATA). DESIGN: A comparison of 8 women undergoing LATA with 11 patients operated on by the same surgeon during a similar time period who were not candidates for, or did not desire, a laparoscopic approach. SETTING: Academic practice tertiary care setting. PATIENTS: Women requesting reversal of tubal ligation. INTERVENTIONS: Tubal anastomosis by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: Patients undergoing the two procedures did not differ by age or parity, although those selected for LATA had a lower body mass index (23.2 +/- 1.4 vs 30.8 +/- 2.0 kg/m2, p = 0.01). Although the LATA took longer (251 +/- 14 vs 194 +/- 10 min, p = 0.004), hospital stay was significantly shorter than for traditional TA (1.8 +/- 0.3 vs 3.0 +/- 0.1 days, p = 0.004). Of the eight LATAs, six were completed and two were converted to laparotomy. For all patients with follow-up, clinical pregnancy rates were 43% and 29% (NS) for TA and LATA, respectively, with 100% of the former and 80% (NS) of the latter group who did not conceive having at least one patent tube on hysterosalpingogram. CONCLUSIONS: Laparoscopic-assisted TA is a possible alternative to the traditional TA performed by laparotomy. Ideal candidates for LATA appear to be women without obesity and with proximal tubal segments of 3 cm or greater. Larger studies with longer follow-up will define appropriate candidates and identify long-term results.

Improved combined laparoscopic and minilaparotomy technique to allow for reversal of extensive tubal sterilization.

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.

Sterilization reversal: results of 101 attempts.

One hundred one patients underwent reversal of sterilization. Among the 79 patients with a known outcome, the successful pregnancy rate was 35%. In contrast, the tubal patency rate was 91%. An analysis of standard preoperative fertility factors failed to reveal their predictive value. Total motile sperm counts of greater than 60 x 10(6) resulted in more successful pregnancies than counts below this number (p less than or equal to 0.005). The operating microscope did not have any advantage over loupes. Patients with one tube greater than 7 cm in length had a delivery rate of 75%, compared with 16% for those with shorter tubes (p less than or equal to 0.001). Eighty percent of patients with a distal segment of the anastomosis that included part of the isthmic tube had deliveries (p less than or equal to 0.029). In contrast, all ectopic pregnancies were associated with a distal segment consisting only of ampulla; the risk of ectopic pregnancy after patent ampullary anastomosis was 23% (p less than or equal to 0.05).