The comparison of the degree of apoptosis in ovaries and fallopian tubes between two different surgical interventions for tubal ligation: A rat model.

OBJECTIVE: To compare the degree of apoptosis in ovaries and tubal epithelium observed secondary to tubal ligation either by Pomeroy's method or bipolar electrocauterization in a rat model. MATERIAL AND METHODS: A total of 24 female Sprague-Dawley rats were randomly assigned into 3 study groups: control (n=8), Pomeroy (n=8), and the electrocauterization group (n=8). Apoptotic cells were detected on the primary, secondary, tertiary follicles of the ovaries, and on the tubal epithelium using terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end-labeling. The apoptotic index was calculated for each group by the percentage of the stained cells. RESULTS: The apoptotic index of tubal epithelium was significantly higher in the bipolar electrocauterization group compared with the control and Pomeroy groups (3.1±0.8 vs. 1.4±1.0, p=0.018 and 2.0±1.2, p=0.03, respectively) whereas there was no significant difference between Pomeroy's method and the control group. The apoptotic index of primary follicles was higher in the bipolar electrocauterization group compared with the control and Pomeroy's method groups (3.4±0.5 vs. 1.2±0.4, p<0.001 and 1.8±0.8, p=0.005, respectively), but there was no significant difference between Pomeroy's method and the control group. The apoptotic index of secondary and tertiary follicles was similar for each group. CONCLUSION: Pomeroy's technique, as a permanent contraception method, is associated with lower apoptotic index on ovary and fallopian tube when compared with bipolar electrocauterization.

A COMPARISON BETWEEN TWO METHODS OF FALLOPIAN TUBAL LIGATION FOR STERILIZATION OF WOMEN IN A LOW RESOURCE SETTING

Objective: To compare two methods of tubal sterilization; modi?ed Pomeroy and a modi?cation added to modi?ed Pomeroy's method, in a low resource setting. In this prospective study conducted from Methods: 2019 to 2021 in one thousand women, we compared Pomeroy's method with an other method in which a slight modi?cation in the original modi?ed Pomeroy's technique was introduced, in a very low resource rural community hospital with only basic operation theater facility. In modi?ed Pomeroy's method, a loop of fallopian tube is resected and trans?xed with 2-0 chromic catgut surgical suture material. In our study we added another modi?cation to the modi?ed Pomeroy's method, wherein the proximal end of the fallopian tube was additionally ligated with a 2-0 silk suture. The patients were followed up from 6months-2 years. A failure rate of 0.4% was observed in women who underwent Modi?ed Pomeroy's method in contrast to no Results: failure in women in whom the proximal end of the tube was additionally ligated. Additional modi?cation to the Conclusion: original modi?ed Pomeroy's method of sterilization can be potentially promising in reduction of sterilization failure rate in parts of world where salpingectomy is less readily accepted

Falope Rings or Modified Pomeroy's Technique for Concurrent Tubal Sterilization.

INTRODUCTION: Sterilization at caesarean section is usually performed by the modified Pomeroy's technique. Application of Falope rings and Filshie clips may also be used for tubal sterilization at caesarean section, and these techniques are also used during laparoscopy or minilaparotomy. OBJECTIVES: The main objective of the study was to evaluate the failure rates, complications, technical difficulties and reversibility of the Falope ring application for tubal sterilization as compared to the traditional modified Pomeroy's technique used during caesarean sections. METHODOLOGY: Five hundred multigravid women who underwent caesarean section for various causes and wanted concurrent tubal sterilization were recruited in the study. Two hundred and fifty women underwent tubal sterilization by Falope ring application and the other 250 by modified Pomeroy's technique. Follow-up period ranged from 3 to 42 months. These patients' names were checked against the antenatal booking register, the operating theatre register in case of ectopic pregnancies and a termination of pregnancy register to recognize failed sterilization. RESULTS: Among the 250 women who underwent Falope ring application, no major complications were noted. In the other group, women who underwent tubal sterilization by modified Pomeroy's technique, there was one woman with serious complication, ectopic pregnancy. Falope ring application was an easy procedure to perform and also less time-consuming than modified Pomeroy's technique. CONCLUSION: Falope ring sterilization is simple, effective and safe, and the rate of subsequent pregnancy is lower than with conventional modified Pomeroy's technique.

The effect of tubal sterilization with the Pomeroy technique and bipolar electrocauterization on the ovarian reserve and serum anti-Müllerian hormone levels in a rat model.

OBJECTIVE: To investigate the effects of tubal sterilization techniques on the ovarian reserve and serum anti-Müllerian hormone (AMH) levels in rats. STUDY DESIGN: Wistar Hannover rats (n=21) were assigned to the following 3 groups (7 rats/group): Pomeroy technique, bipolar electrocauterization, and control. Pre- and postoperative serum AMH levels, ovarian damage and ovarian follicle counts were assessed. RESULTS: Total ovarian damage was higher in the electrocauterization group than in the Pomeroy (p=0.008) and control (p<0.0001) groups. The large antral follicle count was higher in the Pomeroy group than in the electrocauterization (p=0.023) and control (p=0.003) groups. The electrocauterization group had a greater decrease in postoperative serum AMH levels than the Pomeroy and control groups (p=0.031). CONCLUSION: Bipolar electrocauterization may have a negative effect on the ovarian structure and ovarian reserve compared to the Pomeroy technique.

Ruptured ectopic pregnancy after bilateral tubal ligation.

PIP: Two ruptured ectopic pregnancies occurred after Pomeroy tubal ligation. Culdocentesis on both yielded 10 ml of non-clotting blood. After resection and confirmation of decidua and chorionic villi, the patients were discharged on the fifth and seventh day. About 6-7% of maternal mortality in the US is attributed to ruptured ectopic pregnancy and 25% of Pomeroy method failures are estimated to result in ectopic pregnancy.^ieng

Vaginal tubal ligation.

PIP: Postpartum abdominal sterilization by the Pomeroy method or tubal cauterization by laparoscopy are recommended over the procedure of vaginal tubal ligation described by McMaster and Ansari (Obstetrics and Gynecology 38: 44-50. 1971). The abdominal Pomeroy method is quick, and laparoscopy requires a shorter hospital stay. If the uterus is in or can easily be brought into the cul-de-sac, it is advisable to use the vaginal route. Babcock's forceps are not optimal for locating the tube for ligation because the mesosalpinx is clamped blindly, possibly injuring a vessel and causing hematoma. McMaster replies that he performs vaginal ligation chiefly on nonpuerperal grand multipara whose uteri are mid- or retroverted. He disagreed with Brusilow on doing hysterectomy on these patients, but both agreed that vasectomy is preferable if possible.^ieng

Postpartum tubal ligation under local anesthesia.

PIP: Pomeroy tubal ligations were performed on 138 patients between 19-45 years old with an average parity of 4.8 in the early puerperium under local infiltration anesthesia with systemic sedation and analgesia. The optimum dose of diazepam was found to be 0.3 mg/kg. Sterilization was performed for socioeconomic reasons. Two minor anesthetic complications were observed, a thrombophlebitis and an urticarial reaction. Hospital discharge was comparable to that of multiparous women who do not undergo puerperal sterilization.^ieng

Ectopic pregnancy following tubal sterilization surgery.

In a consecutive study of 100 women with the surgical diagnosis of ectopic pregnancy confirmed by histologic examination, 7 women were found to have had prior tubal sterilization surgery. In 3 of these cases the sterilization procedure was bilateral tubal fulguration. The diagnosis of ectopic pregnancy must be given careful consideration if patients conceive after a tubal sterilization procedure of any type.

PIP: From 6 to 10% of all maternal deaths continue to be attributed to ectopic pregnancy, usually the result of hemorrhage. The failure rate of tubal sterilization has been reported to be .25-2% for the Pomeroy procedure and .4-1.7% for bilateral tubal fulguration. The ratio of ectopic to intrauterine pregnancy is higher among pregnancies occurring after sterilizatitn failure than among the general population. The spermatozoa can get past the diminished diameter of a recanalized oviduct but the fertilized ovum cannot pass. During each year about 250 women with ectopic pregnancy are treated at the Los Angeles County-University of Southern California Medical Center. In a review of 100 consecutive cases with a confirmed diagnosis of ectopic pregnancy, 7 were found to have had tubal sterilizaiton surgery 17 months to 8 years previously. In 3 cases, bilateral tubal fulguration had been done and in 4 cases bilateral tubal ligation was performed. Ruptured extrauterine pregnancy had occurred in the distal segment of the tube in 4 and a cornual pregnancy in 1. There was 1 case of aborting tubal gestation and 1 of unruptured tubal pregnancy. In 1 case the tube containing the ectopic pregnancy had not been ligated but the round ligament was by mistake. It is thought the refulguration, as is now done, following transection of the tubes will reduce the incidence of ectopic pregnancies. The diagnosis of ectopic pregnancy should not be excluded because of a patient's history of bilateral tubal ligation or fulguration.

Reconstruction of fallopian tubes in previously sterilized patients.

Restoration of tubal patency after surgical sterilization in which the luminal continutiy is interrupted requires either uterine implantation of the patent distal segment or resection and end-to-end anastomosis of patent adjacent segments. Although it is logical to assume that after most tubal ligations the intramural segment remains normal and end-to-end anastomosis is possible, both segments should be evaluated and tested prior to the plastic reconstruction. The results of 178 operations collected from the literature and the author's 23 attempts at surgical reversal of previous tubal operations for surgical sterilization were described. The over-all pregnancy rate after resection and end-to-end anastomosis was 39.0%; after uterotubal implantation, it was 19.4%. The latter procedure was performed in 60% of the patients. The small series of reports makes it difficult to evaluate conception rates or to judge the merits of specific reconstructive operative techniques.

PIP: This report presents results of 178 cases from the literature and of 23 new attempts at surgical reversal of tubal operations for female sterilization. Operative procedures appropriate for various reanastomosis procedures of previous sterilization are presented tabularly by type of tubal ligation initially performed as well as duration time from sterilization to reconnection. Restoration of tubal patency after surgical sterilization in which the luminal continuity was interrupted required either uterine implantation of the patent distal segment or resection and end-to-end anastomosis of patent adjacent segments. Although it is logical to assume that after most tubal ligations the intramural segment remains normal and end-to-end anastomosis would be possible, both segments should be evaluated and tested before plastic reconstruction. and the latter procedure was performed in 60% of patients.

Tubal polyps, epithelial inclusions, and endometriosis after tubal sterilization.

Histologic findings in 133 previously ligated fallopian tubes of women who underwent subsequent hysterectomy and bilateral salpingectomy were compared with those of 50 normal fallopian tubes and related to four surgical procedures for sterilization. Dilatation of proximal tubal lumen, flattening of the folds, polyps, and increase of mitotic activity of the epithelium was subsequent to tubal occlusion in any case, regardless of the type of sterilization. After sterilization by ring, ligation, and coagulation, the incidence of epithelial inclusions was significantly different from that observed after sterilization by clips. Focal endometriosis was only found after tubal ligation and coagulation. It is suggested that epithelial inclusions were the result of surviving fragments of tubal epithelium translocated in the tubal wall during the procedure, and that endometriosis was caused by implantation of expelled menstrual products through the open lumen into the healed ligation area.

The choice of sterilizing procedure according to its potential reversibility with microsurgery.

Twenty-seven women were evaluated for reversal of previous tubal sterilization in the 2-year span beginning January 1, 1976. Of the thirteen who came to surgery, only seven were able to undergo reanastomosis. Five of these seven had had Pomeroy type ligations and two had ahd "one-burn" electrocoagulation. Six patients who had had "two- or three burn" electrocoagulation did not have sufficient length of fallopian tube remaining. Tubal patency was achieved in 87.5% of those who underwent reanastomosis. The pregnancy rate was 37.5%, with no ectopic pregnancies. Electrocoagulation is not recommended in healthy young women.

PIP: The type of tubal ligation originally performed affects subsequent ability to achieve successful reversal of sterilization procedure. Unfortunately, too little attention has been given to the potential reversibility of a sterilization procedure. This study (spanning 2 years) evaluates 3 groups of women (N=27) for reversal of previous tubal ligation by the Dept. of Obstetrics and Gynecology of the University of Florida. The women were assigned to 3 groups based on the outcome of evaluation (of fertility potential) and surgical procedure performed. Group 1 was comprised of women who came for evaluation but did not have any surgical procedure, while Group 2 consisted of women who had laparoscopic findings precluding any type of reanastomosis; Group 3 consisted of women who had had reanastomosis of at least one tube. The technique described by Winston, with minor modifications, was the microsurgical technique used for reanastomosis. Of the 13 who requested surgery, only 7 underwent reanastomosis; 5 of these had had Pomeroy-type ligations, and 2 had had "1-burn" electrocoagulation. 6 patients who had had "2-or-3 burn" electrocoagulation did not have adequate tubal length. 87.5% of those who were reanastomosed achieved tubal patency. Pregnancy rate was 37.5%, and there were no ectopic pregnancies. Electrocoagulation should be advised for patients with medical indication for permanent sterilization or those who are over 35 years of age. All other cases should utilize techniques with potential for reversibility, while ensuring sterility. Minilap with resection of a small portion of the isthmic segment via the Pomeroy method or its modification appears to be the best procedure to use.

Minilaparotomy under local anesthesia for outpatient sterilization: a preliminary report.

An outpatient sterilization program was started at Silas B. Hays Hospital, Fort Ord, California, and later extended to Malcolm Grow USAF Medical Center and the Walter Reed Army Medical Center. From January 1976 to June 1978, two hundred and eight outpatient minilaparotomy Pomeroy tubal ligations were performed under local anesthesia. The minilaparotomy technique, using standard operating room equipment, is described. The average operating time was 31.8 minutes and the complication rate was 2.5%.

PIP: During the period from January 1976 to June 1978, a series of 208 outpatient minilaparotomy Pomeroy tubal ligations were performed under local anesthesia on an interval basis. The minilaparotomy involves a 3-4 cm transverse incision about 2 fingerbreadths above the pubic symphysis. The major advantage is that it can be performed easily and safely under local anesthesia. In addition, it can be performed with minimal cost, risk and pain in any outpatient clinic. The pre-, post-, and operative procedures for the sterilization patients are described and diagrammed. Following surgery, the patient was observed for 2-4 hours and discharged if no postoperative complications developed. Resumption of normal activities was allowed when the patient was comfortable to do so. Demographic characteristics of the series of patients, previous contraception, and complications encountered are discussed. The average surgical time was 31.8 minutes. The minor complication rate was 2.5%. No major complications occurred.

Complications of female sterilization: immediate and delayed.

Surgical sterilization in women has changed dramatically over the past 20 years. The development of laparoscopy and minilaparotomy have made the procedure readily available even in developing countries. In the United States, changing social values and changes in hospital regulations have done as much as technology to account for the tremendous increases in the number of women undergoing sterilization. Improved sterilization procedures have resulted in lower costs for sterilization and lowered morbidity and mortality rates. Hysterectomy for sterilization alone carries unacceptable morbidity and mortality rates. Originally, laparoscopic techniques utilized unipolar cautery. However, bowel burns, a rare but serious complication, were reported, and this led to newer techniques. These techniques, using bands, clips, and bipolar cautery, have gained increasing popularity and have eliminated many of the serious complications of female sterilization. Historically, there has been concern that tubal sterilization by any method produces, in significant numbers of patients, the subsequent gynecologic and psychologic problems called "post-tubal ligation syndrome." A review of earlier literature indicates that many of these studies have serious methodologic problems, including recall bias, inappropriate control groups, failure to elicit prior history of gynecologic or psychologic problems, and failure to account for the use of oral contraceptives or IUDs. More recent large prospective epidemiologic studies that have controlled for prior gynecologic problems and contraceptive usage have failed to show increased incidence of gynecologic sequelae in large numbers of women. However, there are some data to support the concept that in certain individuals, sterilization may result in disruption of ovarian blood or nerve supply, producing gynecologic sequelae. Additional data from these ongoing large-scale studies and others should help to elucidate this problem in the future. Pregnancy after sterilization (even excluding pregnancies present at the time of the procedure) is more common the first year after the procedure with the risk decreasing in subsequent years.(ABSTRACT TRUNCATED AT 400 WORDS)

PIP: Surgical sterilization has changed dramatically over the past 20 years; the development of laparoscopy and minilaparotomy have made the procedure readily available even in developing countries. Improved sterilization procedures have resulted in lower costs for sterilization and lowered morbidity and mortality rates. Historically there has been concern that tubal sterilization by any method produces, in significant numbers of patients, the post-tubal ligation syndrome. More recent studies that have controlled for prior gynecologic problems and contraceptive usage have failed to show increased incidence of gynecologic sequelae in large numbers of women, but there are data to support the concept that in certain individuals, sterilization may result in disruption of ovarian blood or nerve supply, producing gynecologic sequelae. Data from the Collaborative Review of Sterilization (CREST) conducted by the Centers for Disease Control from 1978-81 are analyzed. Overall complication rates were 42.8% for abdominal hysterectomy and 24.5% for the vaginal procedure. Postoperative febrile morbidity was the most common complication but 0.8% of the abdominal hysterectomies and 1.6% of the vaginal hysterectomies required repeat exploratory operations. In another series of 5018 women 0.45% had bleeding complications during unipolar cautery, 0.29% required laparotomy. In a series of 846 silastic ring sterilizations, 3.1% had bleeding complications but only 2 of these required laparotomy and 1.6% had complications related to the ring technique. It was also shown by the CREST data that: 1) the use of an IUD 1 month prior to sterilization did not alter the risk of complications, 2) sterilization and removal of an IUD should not be performed at the same time, and 3) the risk of requiring laparotomy to complete the sterilization procedure is greater if the woman has a history of previous abdominal or pelvic surgery or obesity greater than 12% of ideal body weight. Pregnancy after sterilization is more common the 1st year after the procedure with the risk decreasing in subsequent years. 1st-year failures are about 0.18-0.37/100 women years and then fall off to 0.1--0.12/100 woman years in subsequent years. The ratio of ectopic pregnancy among these pregnancies is higher after laparoscopic cautery techniques. Band and clips may be slightly less effective than the use of electrocoagulation or the Pomeroy technique. Resection is associated with a slightly higer risk of mesosalpingeal bleeding.

Potential demand for voluntary female sterilization in the 1980s: the compelling need for a nonsurgical method.

PIP: The authors estimate the potential world demand for voluntary sterilization on the basis of U.S. data which shows that 31.3% of U.S. married women of reproductive age are sterilized. If sterilization were equally available elsewhere, they estimate that approximately 180 million procedures would be required during the 1980s, or a five-fold increase over the number now being performed. Of presently available methods colpotomy, culdoscopy, the tantalum clip, and hysteroscopy are not satisfactory. In the author's view, minilaparotomy is the safest procedure, especially when performed by less specialized junior physicians and in rural areas. The most promising new methods use chemicals instilled into the fallopian tubes. Quinacrine pellets inserted through an IUD inserter have an estimated lifetime failure rate of 3/100 women. The authors consider this a safe approach costing about 1/2 as much as surgical sterilization. The quinacrine method has the potential to meet estimated developing country needs and also to be widely used in developed countries. They urge priority for further research on this method.^ieng

Current status of elective sterilization in the United States.

PIP: The desire for smaller families has brought about a change in obstetrics and gynecology with more and more women asking for contraception and elective sterilization. Surveys conducted in 1970 and 1973 found couples choosing sterilization increased from 16.3% to 23.5%. In 1973, 33.7% of couples with wives over age 30 had chosen sterilization. In 1975, 174 sterilizations were performed for every 1000 births, 105 of these postpartum and 69 laparoscopic. The average physician performing laparoscopic sterilization does 62 per year or a little more than 1 per week. Attempts to perform them in clinics or doctors' offices have not proved satisfactory because of the potential major complications. However, they are commonly performed in the hospital on an outpatient basis. Major complication rate in the U.S. (complication requiring laparotomy) is 3.7/1000 cases and the death rate is 2.5/100,000. Compared with the recurrent annual risks of pills and IUDs, which are in the same range as this 1-time only procedure, it is easy to understand why more than 200,000 chose laparoscopic sterilization in 1975. Increasingly younger women are asking for sterilization but the physician is warned to use his common sense and make sure informed consent is obtained. Both the Association for Voluntary Sterilization and the Planned Parenthood Federation of America have patient instruction materials available. Reversibility is still questionable. Reversal of the most popular U.S. procedure, some form of Pomeroy postpartum sterilization, requires laparotomy with isthmic-ampullary anastomosis and has a 20-40% pregnancy rate and an increased risk of ectopic pregnancy. Electrocoagulation as performed in the U.S. destroys the entire isthmic portion of the tube and may require ampullary implantation for reversal. Relatively few have been performed. Microsurgery holds promise although to date fewer than 50 cases have been reported in the literature. Use of clips and bands may improve reversibility. Comparative techniques are briefly summarized. The most popular in the U.S. is postpartum Pomeroy, the 2nd laparoscopic sterilization with a 2-hole technique. Hysterectomy is popular, especially when other gynecological conditions are present; its use is falling with increase in availability of laparoscopy. Colpotomy, culdoscopy, and fimbriectomy are not greatly popular. Studies have given conflicting results for subsequent gynecologic symptoms after sterilization, 1 in Britian suggesting a higher incidence and 1 showing less. The effect on incidence of ectopic pregnancy has not been shown either, although with increased use of sterilization, figures should begin to be available. The Food and Drug Administration is regulating introduction of new devices in this rapidly growing field.^ieng

The evolution of tubal sterilization.

PIP: This review of the evolution of tubal sterilization covers: indications for sterilization; methods of tubal sterilization; outpatient sterilization; and sterilization reversal. Tubal sterilization, as a fertility control method, is a 20th century technique. During the first half of this century, most sterilization procedures were associated with term deliveries and were recommended following a 3rd cesarean section or for multiparous women who had delivered 8 or more living children. Permanent prevention of pregnancy was also considered to be appropriate for most conditions justifying a therapeutic abortion, i.e., medical and psychiatric illnesses and genetic abnormalities. Sterilizations performed solely for contraceptive purposes in healthy individuals who simply chose to terminate childbearing were subjected to a complex formula of age and parity. A change occurred in the late 1960s in both the US and the UK, so that an increasing number of sterilization procedures were performed for contraceptive purposes. As a result of abortion reform laws in the US and the liberalization of family planning concepts that were inherent in it, voluntary sterilizations were performed upon request, the only absolute restriction being a minimum age of 21 years. Data from the sterilization surveillance reports of the Centers for Disease Control show that, between 1970-77, there was a steady increase in the number of sterilizations performed in hospitals in the US. The liberalization of tubal sterilizations during the 1970s shifted the timing of sterilizations away from the puerperal period. This has resulted in an increase in the number of interval sterilization procedures that were performed in hospitals on nonpregnant women. Prior to the late 1960s, most sterilizations were performed via the abdominal route and entailed a 5-7 day hospitalization to allow for wound healing. The most frequently utilized technique was the Pomeroy procedure, in which absorbable suture and excision of a loop is employed. With the introduction of laparoscopic electrocautery tubal sterilization by Steptoe in 1967, prolonged hospitalization became unnecessary. The techniques now being used in the US for laparoscopic sterilization are unipolar electrocautery, bipolar coagulation, and silastic ring and spring clip application. When the nonlaparascopic approach is chosen, the most frequently used procedure is that of minilaparotomy, in which the techniques of Pomeroy ligation, silastic ring, and spring clip applications are used. The sterilization technique offering the greatest potential as an office procedure is that of tubal occlusion with silicone rubber injected through a hysteroscope. Due to the fact that it will not always be possible to recognize those women who may come to regret their sterilization, it is essential to use a procedure that has potential for reversal. Available evidence indicates that the sterilization techniques producing the least tubal damage offer the greatest likelihood of successful reversal.^ieng

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.

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.

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).