Bilateral Tubal Ligation Research Articles

Ectopic tubal pregnancy after hysterectomy and tubal ligation

Posthysterectomy ectopic pregnancy is an unusual condition that may present soon after hysterectomy or several years later. Similarly, although tubal ligation is a widespread method of contraception, tubal pregnancy after tubal ligation is not common either. If any of these conditions are rare, having an ectopic pregnancy after hysterectomy and tubal ligation is even more infrequent and only one of such cases was found in our review of the literature. We describe the case of a 35-year-old patient, with history of bilateral tubal ligation and vaginal hysterectomy that looked for medical attention due to abdominal pain. A pregnancy test was positive and a transvaginal ultrasound demonstrated the presence of a gestational sac at the vaginal cuff, adjacent to the ovary. An exploratory laparotomy showed a ruptured ectopic pregnancy located in the distal portion of the left fallopian tube. The occurrence of an ectopic pregnancy several years following tubal ligation and vaginal hysterectomy is a rare phenomenon that appears to be secondary to a fistulous connection into the peritoneal cavity.

Robotic tubal anastomosis: surgical technique and cost effectiveness

To evaluate the feasibility of robotic microsurgical tubal anastomosis and compare the results and cost effectiveness with the same procedure performed by laparotomy. Prospective cohort study. University hospital. Patients with a history of bilateral tubal ligation who desired reversal for future fertility. Tubal anastomoses through either a robotic approach or through a laparotomy. Operative times, hospitalization, complications, postoperative patency, clinical outcomes, and the cost per live birth. The mean operative time for robotic anastomoses was statistically significantly greater than open anastomoses (ROBOT 201 minutes; OPEN 155.3 minutes), although hospitalization times were statistically significantly shorter (ROBOT 4 hours; OPEN 34.7 hours). The return to instrumental activities of daily living was accelerated in the patients who had undergone a robotic anastomosis (ROBOT 11.1 days; OPEN 28.1 days). Although this was a small series, the pregnancy rates were comparable between groups (ROBOT 62.5%; OPEN 50%), yet the rate of abnormal pregnancy was higher in the robotic group (ectopic: ROBOT 4, OPEN 1; spontaneous pregnancy loss: ROBOT 2, OPEN 1). The cost per delivery was similar between the groups (ROBOT $92,488.00, OPEN $92,205.90). Robotically assisted laparoscopic microsurgical tubal anastomosis is feasible and cost effective with results that are comparable with the traditional open approach.

Uterine rupture presenting as a vaginal prolapse of gangrenous small bowel

The rupture of a gravid uterus is an obstetric disaster associated with high maternal morbidity and mortality [1,2]. To our knowledge, uterine rupture presenting as the vaginal prolapse of a gangrenous bowel has not been previously described. An unbooked 34-year-old woman (gravida 6, para 5 with a living set of twins) presented to Abia State University Teaching Hospital, Aba, Nigeria, with a 2-day history of colicky abdominal pain, vomiting, constipation, and fever. Her condition started after she was delivered at term in a maternity home. The midwives applied fundal pressure to accelerate the second stage of labor, which was reportedly prolonged. The patient eventually delivered a male neonate that died a few hours later. The placenta was said to have been completely delivered, but the patient had a massive postpartum hemorrhage and soon after developed severe colicky abdominal pain. On presentation she was anxious, dehydrated, markedly pale, and distressed with pain. On examination she had generalized tenderness and guarding, exaggerated bowel sounds, and a segment of gangrenous small bowel protruding into the vagina. A clinical diagnosis of ruptured uterus with a vaginal prolapse of gangrenous small bowel was made. As her hematocrit was 22%, resuscitation with intravenous fluids and antibiotics was initiated as preparation was made for emergency exploratory laparotomy. Four units of blood were cross-matched for her. Laparotomy revealed that a 35 cm segment of the ileum was herniated into a 3 cm vertical rupture in the right posterolateral wall of the uterus. The dead ileum segment was resected and end-to-end anastomosis was done, followed by the repair of the uterine rupture and bilateral tubal ligation. The patient had an uneventful recovery. To the best of our knowledge, this is the first report of a ruptured uterus presenting as the vaginal prolapse of a gangrenous small bowel. In this case, the cause of rupture was trauma from the obstetric practice of applying fundal pressure in a prolonged second stage of labor. This case illustrates an unfortunate feature of obstetric care in Nigeria, where many referring centers contribute to the morbidity and mortality of unbooked patients through inadequate care, injudicious interventions, and delay in referral [3,4]. This underscores the need for the better training, support, supervision, and continuous professional development of maternity care providers in Nigeria and other developing countries [2,3].

Tubal ectopic pregnancy after bilateral tubal ligation: A case report

Tubal ligation is a common method of contraception, and pregnancy after this method of sterilization is uncommon. We here present a report of Tubal pregnancy after a Bilateral Tubal Ligation (BTL). The case notes of a 35 year Nigerian female who presented with a tubal pregnancy after BTL and a review of literature on the subject was used. A 35-year-old para 4=0 had bilateral tubal ligation during caesarean section for her last childbirth. She presented 3 years later with a six weeks history of irregular vaginal bleeding and lower abdominal pain and had a laparotomy for a right tubal ectopic pregnancy. Ectopic pregnancy after bilateral tubal ligation is uncommon. Females who undergo BTL should be adequately counseled on the possibility of failure of this procedure for contraception.

Full-term pregnancy in an incisional hernia--a case report

We report a case of full-term pregnancy in a 40 year old woman who presented with her fifth pregnancy with the uterus in the incisional hernia sac hanging below the groin. She has had previous abdominal operation through a midline scar. Complication of the previous operation led to the incisional hernia into which she carried a full term pregnancy. Caesarian section and bilateral tubal ligation were done with repair of the incisional hernia with nonabsorbable suture with uneventful postoperative recovery. It is advised that surgeons carrying out abdominal operations for whatever reason, the operations should be done on fit patient as much as possible, proper incisions should be made and the fascia should be closed with non-absorbable sutures (mass closure) in order to avoid occurrence of incisional hernias. Emergency operations in the abdomen including caesarian section, surgical principles should always be observed.

Diagnosis of polycystic ovarian syndrome (PCOS) or endometriosis is associated with lower pregnancy rates in women undergoing in vitro fertilization and embryo transfer (IVF-ET)

To determine outcome of IVF-ET in women with a diagnosis of PCOS or endometriosis compared to a control group of fertile women with tubal ligation who underwent IVF-ET. A case-control study. The study included 813 consecutive women who underwent IVF-ET treatment from 2002 & 2005 with the diagnosis of PCOS (NIH-consensus criteria) in 408 women and endometriosis (confirmed surgically) in 354 women. The rest of the women included a control group of 51 women who underwent IVF-ET because of bilateral tubal ligation. The control group included women with proven fertility (including their male partners). Primary outcome included clinical pregnancy rate while secondary outcomes included implantation rate, pregnancy loss rate & cycle characteristics. Statistical analysis was done comparing the control group (tubal ligation) with the each one of the other two study groups (endometriosis & PCOS groups). There was no statistically significant difference between the control and each of the study groups as regards age, type of stimulation protocol or number of retrieved mature oocytes. Clinical pregnancy rate was significantly lower in each of the study groups compared to the control group while the rate of pregnancy loss was significantly lower in the control group. Table 1Characteristics & treatment outcomes in women <35 yrs & ≥35 yrs<35 Yrs≥35 YrsEndometriosisPCOSTubal LigationEndometriosisPCOSTubal LigationIVF-ET Cycles∗2283071912610132Pregnancies∗124 (54%)158 (52%)12 (63%)62 (49%)46 (46%)16 (50%)Clinical Pregnancies∗100 (44%)136 (44%)12 (63%)46 (37%)36 (36%)14 (44%)Pregnancy loss∗24 (19%)22 (14%)0 (0%)16 (26%)10 (22%)2 (13%)Implantation rate24%28%31%16%19%23%Embryos transferred∗∗2.8 ± 12.7 ± 12.7 ± 13.2 ± 13 ± 12.9 ± 1Age∗∗31 ± 2.830 ± 3.231 ± 2.737 ± 2.237 ± 2.239 ± 2.8Data presented as: Number (rate)∗ and Mean ± SD∗∗. Open table in a new tab Data presented as: Number (rate)∗ and Mean ± SD∗∗. Compared to a cohort of control group that included women with proved fertility (tubal ligation), the diagnosis of endometriosis or PCOS was associated less favorable treatment outcomes (lower clinical pregnancy rates and higher rates of pregnancy loss).

Endoloop application as an alternative method for gastrotomy closure in experimental transgastric surgery

Experimental studies investigating transgastric endoscopic surgery report closure of the gastric wall incision with clips. The author of this report describes endoloop placement as an alternative, equally efficient, faster method for gastrotomy closure. Eight female pigs with a mean weight of 30 kg were used. Abdominal endoscopic exploration and transgastric operations including hepatic biopsies, bilateral tubal ligation, cholecystectomy, and closure of the gastrotomy were performed. The experiment was divided into two parts. The first part included five animals, which were killed immediately after the procedure. The second part included five animals, which were kept alive and killed 15 to 20 days later. The first part of the experiment, performed for technical skills acquisition, involved transgastric abdominal exploration, liver biopsies, and bilateral tubal ligation, which were successful for all five animals. The gastric wall incision was closed by applying clips in four animals and endoloops in one animal. During the autopsy at the end of the experiment, the sites of intervention were examined macroscopically. In the second part of the experiment, gastrotomy closure with endoloop application was performed in two animals and with clip application in one animal. All three animals survived, gained weight, and demonstrated no signs of infection. They were killed 15 to 20 days after the procedure, and no signs of intraabdominal infection were found. Cultures from the peritoneal cavity were negative. At necropsy, macroscopic and microscopic examination confirmed complete healing of the gastrotomy. Transgastric endoscopic surgery is technically feasible and effective. The application of endoloops for closure of the gastric opening is a fast, easy, and equally safe alternative to clip placement.

Closure of Gastrotomy After Transgastric Tubal Ligation Using the Eagle Claw VII-A Survival Experiment in a Porcine Model

Background: The main barrier to the safe introduction of Natural Orifice Translumenal Endsocopic Surgery (NOTES) through stomach is secure closure of the gastrostomy. We tested the security of closure of gastrotomy using a prototype endoscopic suturing device-Eagle Claw VII. Method: We performed the procedures under GA in pigs weighted 50 kg. We employed double channel endoscope and inserting a long overtube to esophagus. The stomach was flushed with 1000 mls neomycin solution, and gastric puncture was performed using needle knife papillotome. This was extended with sphincterotome. The endoscope then passed via gastrotomy into the peritoneal cavity. The Fallopian tube was identified adjacent to the ovary. Bilateral tubal ligation was performed using double endoloops. The tubes were transected using needle knife. Closure of the gastrotomy was performed using the Eagle Claw VII by full thickness suturing. The sutures were tightened intracorporeally using a detachable needle tip engaged in plastic casing. The suture used is 3-O nylon. The pigs were allowed to survived for 2 weeks before euthanasia. Results: We performed transgastric bilateral tubal ligation and closure of gastrotomy in 3 pigs. The average operative time was 180 minutes. All the closures of gastrotomy were performed with 3 interrupted sutures through Eagle Claw. All the pigs tolerated diet well. Follow-up endoscopy was performed 2 weeks later and all closures were completely healed. Laparotomy was then performed and all the gastrotomy closures were confirmed to be intact without evidence of leakage. Conclusions: The gastrotomy after transgastric surgery can be safely and securely closed with Eagle Claw VII.

A review of bilateral tubal ligation at caesarean section in Jos, Nigeria

The advent of minilaparotomy under local anaesthesia has revolutionalised the performance of bilateral tubal ligation for permanent contraception in Jos. Female sterilisation has however continued to be performed during caesarean section mainly for obstetric or surgical reasons. To determine the incidence of bilateral tubal ligation during caesarean section, and the trend over the years in Jos, Nigeria. This was a retrospective analysis of the register of all bilateral tubal ligations including those performed at caesarean section, between January 1985 and December 2000 (16 years). A total of 3,585 female sterilisations were performed, and 533 (14.9%) were at caesarean section. The rest were through minilaparotomy under local anaesthesia (84.3%) and laparoscopy (0.7). The yearly rate of tubal ligation at caesarean section declined from 33.8% in 1985 to 16.3% in 2000. The commonest indication for the tubal ligation during caesarean section was repeat caesarean section, and accounted for 55.5%. The mean age and parity of the women were 32.1 years and 5.0 respectively. The mean of the number of children of the women at the time of the caesarean section was 4.5. There was a significant difference in age, parity and number of living children of the women compared with those that had bilateral tubal ligation at times other than during caesarean section. There was no complication specific to the tubal ligation at caesarean section. About 15% of all female sterilisations were performed at caesarean section. The trend demonstrated a decline, probably influenced by the advent of minilaparotomy under local anaesthesia in Jos, Nigeria.

P-372: Serum markers of endometriosis: A proteomics approach to diagnosis

P-372: Serum markers of endometriosis: A proteomics approach to diagnosis

P-451: Obturator hernia presenting as a cause of recurrent pain in a patient with previously diagnosed endometriosis

To describe a patient with recurrent pelvic endometriosis who was discovered to have an obturator hernia at the time of laparoscopy. Case report. A 47 year old multiparous Caucasian woman with a 10 year history of chronic pelvic pain and laparoscopically diagnosed endometriosis presented with complaints of constant, right-sided pelvic pain, localized to a pin-point area in her right pelvis. She also noted a pulling sensation down the anterior and posterior surfaces of her right leg, dyspareunia and dysmenorrhea, but no gastrointestinal complaints. Six years ago, she had undergone laparoscopic fulguration of pelvic endometriosis and bilateral tubal ligation. Her pain had improved for 8-12 months post-operatively, but recurred thereafter and remained persistent. Subsequent treatment was with oral contraceptive pills taken continuously. The patient enrolled in a clinical protocol studying the Neural Immune Mechanisms and Genetic Influences of Chronic Pelvic Pain and endometriosis. As part of the study protocol, the patient underwent a laparoscopy which revealed a right obturator hernia in addition to endometrial implants in the anterior and posterior cul-de-sac, left ovarian fossa and left uterosacral ligament. The proximal portion of both fallopian tubes were surgically absent and the ovaries appeared normal. Endometriotic implants were excised with Nd:YAG laser. The obturator hernia contained peritoneum, but no bowel. The redundant peritoneum was everted, excised and Marlex mesh was used to seal the defect. Two weeks post-operatively, the patient noted some improvement of her pain. Controversy exists as to the optimal treatment for recurrent pain associated with endometriosis with many arguing for use of medical therapy rather than repeat surgery. In a setting of recurrent pain in a patient with previously diagnosed endometriosis, it is easy to assume that pain is due to disease recurrence. In this particular situation, however, this patient became symptomatic on medical treatment. At surgery, it was difficult to attribute the pain definitively to either endometriosis or the hernia. Yet, an obturator hernia would not have been discovered unless she had laparoscopic surgery. Late diagnosis of obturator hernia has been associated with bowel obstruction and morbidity and mortality reported as high as 25%. In patients with recurrent chronic pelvic pain, physicians should also consider non-gynecologic etiologies. The threshold to perform a laparoscopy should be low, especially in those not responding to medical treatment. It is critical to balance the risks of laparoscopy with the risks of missing treatable disease. The consequences of missed diagnosis may be life-threatening in some cases.

Randomized trial to evaluate the use of a flexible self-retaining retractor for postpartum tubal sterilization: a pilot study

Postpartum tubal ligation is a safe and effective means of contraception, but it is being performed less frequently than in the past. One reason for the decrease includes inconvenient scheduling for the physician. If a device that makes surgery easier to perform were available, perhaps more physicians would offer this option. In this study, we sought to compare a flexible self-retaining retractor (Mobius��; Apple Medical Corporation) with standard metal retractors (Army���Navy) for use in postpartum bilateral tubal ligation.

Ruptured uterus in a primigravida, secondary to abdominal manipulation by a traditional birth attendant: a case report

Rupture of the gravid uterus is a life threatening obstetric complication which is a rare event in the primigravida. We present a case of uterine rupture in a 34 year-old unbooked primigravida. She presented in labour post-term to a traditional birth attendant who carried out an abdominal manipulation to correct a suspected oblique lie. Soon afterward she developed severe epigastric pain and breathlessness and was referred to our center. Findings at operation included a live female baby weighing 2.9kg and 6 cm transverse posterio-fundal rupture. Repair of the uterine rupture was done without bilateral tubal ligation. Keywords : uterus, rupture, TBA, manipulation Tropical Journal of Obstetrics and Gynaecology Vol. 22(1) 2005: 83-84

Contraceptive pattern at a comprehensive health center in a sub-urban setting

Context: The Gindiri Comprehensive Health Center (CHC) is about 76 km from Jos and serves the local population. It provides health care services to patients in addition to providing contraceptive services to desiring clients. Objective: To evaluate the pattern of contraceptive acceptability and the preferred methods of contraception accepted by the population. Methodology: This was a descriptive review of the records of the family planning clinic of the Comprehensive Health Center, Gindiri, between January 1990 and December 2003.Results: A total of 651 new clients accepted contraceptive methods within the period of study. There was a gradual decline in the new acceptors over the period from 238 in 1990-1991 to 56 in 2002-2003. The mean age and parity were 32.4 ± 3.6 and 5.0 ± 2.4 respectively. There was no record of males accepting any method of contraception. The commonest accepted method of contraception accepted most by the clients was the pill 295 (45.3%), followed by the Injectable 254 (39.0%). Bilateral tubal ligation (BTL) was the least acceptable by the clients in 8 (1.2%) clients. Conclusion: There was a gradual decline in new acceptors of contraceptive methods in the center over the years. The men were not accepting any form of contraception. Men need more information in order to utilize the service or encourage their spouses to use the available methods. Keywords: contraception, clients, the pill, comprehensive health center, Gindiri Tropical Journal of Obstetrics and Gynaecology Vol. 22(2) 2005: 144-146

Identifying women who will request sterilization reversal in a military population

Objective We sought to identify the characteristics of women in a military population who are likely to seek a tubal anastomosis after a previous bilateral tubal ligation (BTL). Method A written investigational review board-approved questionnaire was administered to 56 women, ages 18–40 years, requesting evaluation for a reversal of a prior BTL and 52 women of the same age range not seeking reversal. The questionnaire identified demographics and relationship characteristics of volunteers at the time of their decision to have a BTL and at the present time. Results Age 25 years or younger, sterilization due to pressure from a partner, poor marital relationship at the time of the BTL and a new marriage are highly predictive of tubal sterilization regret and a request for sterilization reversal in a military population. In addition, women requesting a tubal anastomosis reported less preoperative counseling on the permanence of a BTL and of the male alternative for permanent female sterilization, vasectomy. Conclusion Women with these characteristics should have extensive counseling before undergoing tubal sterilization.

Dysfunctional uterine bleeding - association with bilateral tubal ligation?

Objective: To find an association between Dysfunctional uterine bleeding (DUB) and prior Bilateral tubal ligation (BTL). Design: Observational study. Place and duration of study: Unit II, Lady Willingdon Hospital, Lahore, from August to December 2006. Patients and methods: Fifty two patients between the ages of 35 to 46 with abnormal uterine bleeding (AUB) were studied. Exclusion criteria included intrauterine device (IUD), evidence of pregnancy, leiomyoma or ovarian pathology on sonography, uterine size of greater than 10 cm, medical disorders and hormonal therapy. All patients were worked up for underlying cause of AUB, assessed for BTL and divided in two groups. Group A of 27 patients with previous history of BTL and Group B of 25 patients without previous history of BTL. Results: In group A (with prior BTL), 22 patients ( 81%) had DUB as compared to 12 (48%) in group B (without prior BTL) and this difference was statistically significant ( p< 0.05 ). Conclusion: In women undergoing diagnostic work up for AUB the likelihood of DUB being the underlying cause is greater if they have prior BTL.

The effect of tubal ligation scoring and sterilization counseling on the request for tubal reanastomosis

Objective The aim of this study is to emphasize the role of counseling methods that are meant to decrease the request for tubal ligation reversal, such as tubal ligation scoring.Method This study covers 389 patients who were admitted for tubal sterilization to Çukurova University, Faculty of Medicine, Obstetrics and Gynecology Department, between 1 January 1990 and 31 December 1999. We have used the ‘Tubal ligation score’ on these 389 patients. Four hundred and seventeen patients who underwent bilateral Pomeroy type tubal ligation during cesarean section without having undergone tubal ligation scoring in the same time interval, were accepted as the control group.Results Laparoscopic tubal ligation (with a Yoon ring) was performed on 368 patients who had a score of 6 or higher. Twenty-one patients who got a score of 6 or lower were recounseled and another family planning method was prescribed to them. None of the 368 patients to whom tubal ligation scoring was done previous to laparoscopic tubal ligation returned to our clinic for tubal reanastomosis. Fifteen of the 417 patients (3.6%) in the control group returned to our clinic for tubal reanastomosis.ConclusionTubal ligation scoring may decrease the ratio of patients who request a tubal ligation reversal.

Risk Factors Associated with the Rupture of Tubal Ectopic Pregnancy

Objective: To identify risk factors that may lead to the rupture of ectopic pregnancies. Study Design: A retrospective chart review was performed on patients with ectopic pregnancies at the University of Miami/Jackson Memorial Hospital between 1/1/1995 and 3/1/2002. 738 patients were identified with ectopic pregnancies. Women with tubal rupture were compared to those without rupture. Variables analyzed were demographic data, patient-related risk factors (history of pelvic surgery, bilateral tubal ligation, history of pelvic inflammatory disease, previous ectopic pregnancy, intrauterine device use) and β-human chorionic gonadotropin (βhCG) measurement. Results: There were 439 (59%) cases with a ruptured and 299 (41%) cases with an unruptured ectopic pregnancy. Multivariate logistic regression analysis revealed that previous ectopic pregnancy (OR 2.88; 95% CI 1.92, 4.33) and βhCG level ≧5,000 mIU/ml (OR 1.85; 95% CI 1.12, 3.06) were the only significant risk factors for tubal rupture. Conclusion: Patients with βhCG levels ≧5,000 mIU/ml and patients with a history of a previous ectopic pregnancy are significantly more likely to experience a tubal rupture.

Intrathecal Morphine for Analgesia after Postpartum Bilateral Tubal Ligation

Intrathecal Morphine for Analgesia after Postpartum Bilateral Tubal Ligation

Intrathecal Morphine for Postpartum Bilateral Tubal Ligation

Intrathecal Morphine for Postpartum Bilateral Tubal Ligation