Tubal Sterilization Procedures Research Articles

A Decision Aid to Support Tubal Sterilization Decision-Making Among Pregnant Women

Tubal sterilization is common, especially among individuals with low income. There is substantial misunderstanding about sterilization among those who have undergone the procedure, suggesting suboptimal decision-making about a method that permanently ends reproductive capacity. To test the efficacy of a web-based decision aid for improving tubal sterilization decision quality. This randomized clinical trial conducted between March 2020 and November 2023 included English- or Spanish-speaking pregnant cisgender women aged 21 to 45 years who had Medicaid insurance and were contemplating tubal sterilization after delivery. Participants were recruited from outpatient obstetric clinics in 3 US cities. Participants were randomized 1:1 to usual care (control arm) or to usual care plus a web-based decision aid (MyDecision/MiDecisión) (intervention arm). The aid includes written, audio, and video information about tubal sterilization procedures; an interactive table comparing contraceptive options; values-clarifying exercises; knowledge checks; and a summary report. The co-primary outcomes were tubal sterilization knowledge and decisional conflict regarding the contraceptive decision. Knowledge was measured as the percentage of correct responses to 10 true-false items. Decisional conflict was measured using the low-literacy Decision Conflict Scale, with lower scores on a range from 0 to 100 indicating less conflict. Among the 350 participants, mean (SD) age was 29.7 (5.1) years. Compared with the usual care group, participants randomized to the decision aid had significantly higher tubal sterilization knowledge (mean [SD] proportion of questions answered correctly, 76.5% [16.9%] vs 55.6% [22.6%]; P < .001) and lower decisional conflict scores (mean [SD], 12.7 [16.6] vs 18.7 [20.8] points; P = .002). The greatest knowledge differences between the 2 groups were for items about permanence, with more participants in the intervention arm answering correctly that tubal sterilization is not easily reversible (90.1% vs 39.3%; odds ratio [OR], 14.2 [95% CI, 7.9-25.4]; P < .001) and that the tubes do not spontaneously "come untied" (86.6% vs 33.7%; OR, 13.0 [95% CI, 7.6-22.4]; P < .001). MyDecision/MiDecisión significantly improved tubal sterilization decision-making quality compared with usual care only. This scalable decision aid can be implemented into clinical practice to supplement practitioner counseling. These results are particularly important given the recent increase in demand for permanent contraception after the US Supreme Court decision overturning federal abortion protections. ClinicalTrials.gov Identifier: NCT04097717.

Development of My Decision/Mi Decisión, a web-based decision aid to support permanent contraception decision making

ObjectiveTo develop a patient-centered, web-based decision aid to support informed and value-concordant decision making among Medicaid enrollees considering tubal sterilization. MethodsWe used the Ottawa Decision Support Framework and the International Patient Decision Aids Standards (IPDAS) to guide systematic development of our decision aid. We interviewed 15 obstetrician-gynecologists and 40 women, who had considered or were considering tubal sterilization. A Steering Committee—comprising healthcare providers, social scientists, reproductive health and justice advocates, and people with lived experience—provided feedback and direction. We developed English and Spanish prototypes, which were beta tested with 24 women. ResultsThe resulting web-based My Decision/Mi Decisión tool (English/Spanish) includes written and video information about tubal sterilization procedures; an interactive table of contraception options; values clarification exercises; reflection and deliberation; knowledge checks; and a summary report to share with one's provider. Users found the decision aid to be informative, engaging, easy to use, and helpful in informing contraception decision making. ConclusionMy Decision/Mi Decisión is a scalable tool that could be implemented widely to support informed decision making about tubal sterilization. InnovationThis is a novel and timely web-based decision tool for tubal sterilization, when demand for permanent contraception is rapidly increasing post-Dobbs. While designed for Medicaid enrollees, further investigation will explore more generalized use.

Risk of Sterilization Regret and Age: An Analysis of the National Survey of Family Growth, 2015-2019.

To estimate the risk of sterilization regret based on age at the time of sterilization in a contemporary group of women. We conducted a retrospective analysis of cross-sectional data from the 2015-2017 and 2017-2019 National Survey of Family Growth, Female Respondent Files, to estimate the proportion of women who experience sterilization regret. Descriptive statistics were used to describe the population and the proportion with regret. Sterilization regret was defined as someone who either underwent sterilization reversal or who definitely wanted sterilization reversal. Multivariable logistic regression models were used to assess associations with sterilization regret. A total of 1,549 women who underwent sterilization were included in the analysis; 8% were aged 21-30 years, and 92% were aged older than 30 years. Of the participants, 16.9% identified as Black, 22.0% as Hispanic, and 57.2% as White. Most (58.4%) underwent a tubal sterilization procedure between age 21 and 30 years. The cumulative proportion of regret was 10.2% (12.6% for women who underwent sterilization at age 21-30 years and 6.7% for those who underwent sterilization at older than age 30 years). After controlling for covariates including age, race, parity, educational attainment, and medical reason for sterilization, the only variable that had a statistically significant association with regret was age at the time of the interview (P<.001). As women got older, they were less likely to report sterilization regret. Younger women experience more sterilization regret. As women get older, sterilization regret decreases. Counseling about sterilization should reveal the unpredictability of future desire, but age alone must not be a barrier to performing sterilization.

Trends in opportunistic salpingectomy following vaginal delivery

<h3>Objectives:</h3> The fallopian tube has been implicated as the site of origin in up to 70% of ovarian carcinomas. In November 2013, the Society of Gynecologic Oncology (SGO) advised that women of average risk for ovarian cancer undergo opportunistic salpingectomy at the time of abdominal or pelvic surgery, such as hysterectomy or tubal sterilization, to reduce the risk of ovarian cancer. Opportunistic salpingectomy has previously been incorporated into various surgical procedures including cesarean section, however a paucity of data exists regarding salpingectomy following vaginal deliveries. Our objective was to assess the uptake of opportunistic salpingectomy as a form of postpartum sterilization after vaginal delivery following the 2013 release of the SGO clinical practice statement. <h3>Methods:</h3> We performed an IRB-approved, retrospective cohort study of all postpartum tubal sterilization procedures performed during delivery admissions between January 2009 and December 2019. All patients undergoing tubal sterilization within 48 hours of vaginal delivery were included. We collected patient demographics, medical history, peripartum and perioperative data. The primary outcome was proportion of sterilization procedures completed as salpingectomies before and after January 1st, 2014. Secondary outcomes included estimated blood loss (EBL), perioperative complications and readmission within 6 weeks postpartum. We used Pearson's c2 test, Fisher's exact and Student's t-test to compare the time periods. We analyzed trends using the Cochran-Mantel-Haenszel test. <h3>Results:</h3> A total of 317 postpartum sterilization procedures were performed during the study period. 113 salpingectomies were performed during or after 2014 (<i>p</i>-value < 0.001). Patient demographics before and after January 1st, 2014 did not significantly differ. In 2014, 5.9% of sterilization procedures were completed as salpingectomies. By 2019, salpingectomies comprised 80% of postpartum sterilization procedures (Figure 1, p-value for trend < 0.001). Prior to 2014, the majority of tubal sterilizations occurred with placement of occlusive Filshie Clips (53.7%). Their use decreased to 0% by 2016 (p-value for trend < 0.001). There were no differences in EBL, postoperative complications or readmission during the time periods studied. Patients undergoing tubal sterilization prior to 2014 were more likely to be prescribed opioids at discharge compared to after (OR 0.37, 95% CI [0.20-0.70]). <h3>Conclusions:</h3> Postpartum opportunistic salpingectomy rates following vaginal deliveries increased significantly from 2014 to 2019 after the release of the SGO recommendations to consider salpingectomy as an ovarian cancer prevention strategy. This trend in postpartum salpingectomy occurred without an observed increase in complications or readmissions. Opportunistic salpingectomy should be considered a safe and feasible means of potential ovarian cancer risk reduction for patients who undergo vaginal deliveries and desire immediate postpartum sterilization.

Risk-Reducing Salpingectomy Versus Standard Tubal Sterilization: Lessons From Offering Women Options for Interval Sterilization.

In women receiving sterilization, the removal of the entire fallopian tube, a procedure referred to as a risk-reducing salpingectomy (RRS), reduces subsequent ovarian cancer risk compared with standard tubal sterilization procedures. There are limited data on which surgical procedure women will choose when educated about the benefits of an RRS. Our objective was to study the proportion of women desiring sterilization that would choose an RRS. This cohort study included women 30 years of age and older with a living biological child who requested laparoscopic sterilization at a tertiary academic hospital. Participants were given a decision aid and offered an RRS or a standard tubal sterilization procedure with titanium clips. The primary outcome was to determine the proportion of women who would choose an RRS. Other outcomes included estimated blood loss and operative time, which was compared between groups, along with complications. Fourteen of the 18 (78%) women who participated in our study chose RRS. Estimated blood loss and operating time were similar among women who underwent RRS and standard tubal sterilizations. There were no significant complications in either group. The study was ended early based on emerging data and a change in national practice patterns. Because of the elective nature of sterilization and the complexities of cancer risk reduction, a patient-centered approach is beneficial for sterilization counseling. Our results support offering RRS as an alternative to standard tubal sterilization.

Comparing Outcomes of Hysteroscopic and Laparoscopic Tubal Sterilization

In the U.S., some 600,000 female tubal sterilization procedures are performed annually, most often laparoscopically or hysteroscopically if outside the

Effectiveness of in vitro fertilization in women with previous tubal sterilization

ObjectiveThe objective was to determine the effectiveness of in vitro fertilization (IVF) on live-delivery rates in women who had previously undergone tubal sterilization. Study designWe examined first IVF live deliveries for women aged 20–44 years at their first embryo transfer (ET) with history of hospital admission for tubal sterilization in Western Australia (WA). The ET cycles (n=178) were ascertained over the period of 1996 to 2010 using WA hospital records. A control group of subfertile women matched by age was randomly selected (n=178). We used Kaplan–Meier curves and life-table analysis to evaluate the cumulative live-delivery rates. ResultsAn overall cumulative live-delivery rate in women who had undergone previous tubal sterilization (31%) was comparable to that of subfertile controls (34%) within the first 24 months. Younger women (aged 20–34 years) with previous sterilization (34%) were slightly more likely to deliver an IVF live baby than older women (aged 35–39 and 40–44 years) (33% and 22%, respectively), although this difference was not statistically significant (p=.449). ConclusionWomen who desire fertility after a tubal sterilization procedure and undergo IVF have rates of pregnancy similar to age-matched subfertile IVF control patients. ImplicationsIn vitro fertilization success in women who had undergone previous tubal sterilization is similar to that of the subfertile controls and thus does not depend on past fertility. Age is the most important predictive factor in achieving pregnancy.

English

AIMS: Evaluation of risk factors, variable clinical presentations, and study of outcome of ectopic pregnancy by surgical and medical management. STUDY DESIGN: PROSPECTIVE STUDY: METHODS: All the women with ectopic pregnancy managed from May 2009 to December 2012 by surgical and medical management were analyzed prospectively. RESULTS: In our study incidence of ectopic pregnancy was 12.46 per 1000 live births. Forty-three patients of ectopic pregnancy were under the study in which there was not observed maternal mortality. Abdominal pain and amenorrhoea (97.67%) were the most common symptoms followed by vaginal bleeding (53.49%). Tenderness over lower abdomen was seen in 33 (76.74%) patients and the classical sign of cervical motion tenderness was seen in 19(44.19%) cases. Pelvic inflammatory disease (16.28%), repeat ectopic (11.63%), failed tubal sterilization procedures (11.63%) were the major risk factors. Salpingectomy was done in 35(81.39 %) cases, salpingooophorectomy in 1(2.32%) case, D&C followed by laparoscopic salpingectomy was done in 1(2.32%) case and 4(9.30%) cases were managed by medical methods. CONCLUSION: In spite of the various recent advances in the management of ectopic pregnancy, surgical management by laparotomy is still the most widely used modality of treatment in our institution because of late referrals.

Tubal sterilization: pregnancy rates after hysteroscopic versus laparoscopic sterilization in France, 2006–2010

ObjectiveTo compare the rates of pregnancy among women who underwent Essure® hysteroscopic sterilization versus tubal ligation in France between 2006 and 2010. Study designRetrospective cohort study. SettingHospital care in France (nationwide). Anonymised database of all hospital discharge summaries in France. PatientsRecruitment was based on procedure codes in the national database of hospital discharge summaries. The study included all women who underwent tubal sterilization by Essure® microinserts or by tubal ligation and subsequently were hospitalised either for all unexpected pregnancies related diagnosis (e.g., miscarriage, legal abortion, or delivery) or for pregnancies following reversal microsurgery or invitro fertilization (IVF) treatment. Measurements and main resultsDuring the study period, French hospitals performed 109,277 tubal sterilization procedures: 39,169 Essure® sterilizations and 70,108 laparoscopic tubal ligations. The respective indication of both techniques depended on the surgeons’ skill. The median age of the two populations was similar, 41 years (range 28–52) for Essure® patients and 40 years (range 27–54) for those undergoing tubal ligation (p=0.42). A Cox model has been performed.Following sterilization, after adjustment on age Essure® patients became pregnant at a significantly lower rate than laparoscopic ligation patients 0.36% versus 0.46%, respectively (HR=0.62 (040–096)), and their pregnancy rate of post-sterilization procedure was significantly lower (reversal microsurgeries: 0.02% versus 0.19% (p<0.001), IVF treatment: 0.08% versus 0.27%) (p<0.001). The pregnancy rates after IVF were 12.5% and 5.35%, respectively, and 0% and 11.36% after tubal repair. ConclusionThis nationwide study of tubal sterilization demonstrates that Essure® was associated with lower rates of pregnancy versus tubal ligation.

Minimally invasive versus open surgery for reversal of tubal sterilization

Although tubal sterilization procedures are considered to be permanent, requests for reversal of the procedure (re-canalisation) are not infrequent. The reversal procedure can be done either by an open laparotomy or by minimally invasive surgery (laparoscopic or robotic approach). To compare the relative effectiveness and safety of reversal of tubal sterilization by open laparotomy, laparoscopy and robotically assisted endoscopy. On 23 October 2012 we searched the Cochrane Menstrual Disorders and Subfertility Review Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 10, 2012); MEDLINE; EMBASE; LILACS; clinical trials registries; regional databases; conference proceedings; and references for relevant published, unpublished and ongoing trials. Randomised trials comparing the different methods of surgical reversal of tubal sterilisation. No trials that met the selection criteria were identified. No data for evaluation were obtained Currently there is no evidence from randomised controlled trials to recommend or refute the use of a minimally invasive surgical approach (laparoscopic or robotic) or open surgery for reversal of tubal sterilization. There is a need for well conducted and reported randomised clinical trials to generate reliable evidence to inform clinical practice.

Comparison of Tubal Sterilization Procedures Performed by Keyless Abdominal Rope-Lifting Surgery and Conventional CO2Laparoscopy: A Case Controlled Clinical Study

Objective. To evaluate the safety and efficacy of Keyless Abdominal Rope-Lifting Surgery (KARS), for tubal sterilization procedures in comparison with the conventional CO2 laparoscopy. Material and Methods. During a one-year period, 71 women underwent tubal ligation surgery. Conventional laparoscopy (N = 38) and KARS (N = 33) were used for tubal sterilization. In KARS, an abdominal access pathway through a single intra-abdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intraumbilical entry without the use of trocars. In CO2 laparoscopy, following the creation of the CO2 pneumoperitoneum a 10 mm trocar and two 5 mm trocars were introduced into the abdominal cavity. Tubal sterilizations were performed following the creation of the abdominal access pathways in both groups. The groups were compared with each other. Results. All operations could be performed by KARS without conversion to CO2 laparoscopy or laparotomy. The mean operative time of the two groups was not significantly different (P > 0.05). Intra- and postoperative findings including complications, bleeding, and hospital stay time did not differ between groups (P > 0.05). Conclusion. KARS for tubal sterilization seems safe and effective in terms of cosmesis, postoperative pain, and early hospital discharge.

Effect of cigarette smoking on human oviductal ciliation and ciliogenesis

To investigate the effect of cigarette smoke exposure on ciliation and ciliogenesis in human oviductal epithelium. Molecular analysis using human tubal segments. Academic medical center. Twenty women undergoing elective tubal sterilization procedure. Expression of ciliated cell-specific markers was compared in tubal segments from smokers and nonsmokers using quantitative immunohistochemistry and Western blot analysis. The expression of transcription factors in the motile ciliogenesis program was compared using quantitative polymerase chain reaction and quantitative immunohistochemistry. Oviductal ciliation and expression of transcription factors involved in ciliogenesis. No significant differences were detected in density of ciliation between groups. Neither number of years of smoking nor pack-year history correlated with density of ciliation. Expression of ciliogenic transcription factors FOXJ1, RFX2, and RFX3 was consistent between groups. Few studies have evaluated the relationship between smoking and ciliated epithelium in human oviducts. Cigarette smoking does not seem to result in quantitative differences in the density of ciliation nor expression of ciliogenesis factors. Our findings suggest that pathophysiologic mechanisms other than ciliation account for the increased risk of ectopic pregnancy in women who smoke.

Tubal sterilization during cesarean section or as an elective procedure? Effect on the ovarian reserve

BackgroundThe purpose of this study is to compare the effects of tubal sterilization on the ovarian reserve by means of hormonal and ultrasonographic evaluation during a cesarean section or when performed as a planned interval procedure. Study DesignFifty women who had undergone tubal sterilization during a cesarean section (n=24) and by minilaparotomy as an elective procedure (n=26) were included in the study. Tubes were ligated with the Pomeroy technique in both groups. The women who had chosen to use barrier method or intrauterine device for contraception (n=30) constituted the control group. Among the women in the control group, two separate control groups were constituted (control 1 and control 2) who were age matched with the women in each study group. Hormone levels including antimüllerian hormone (AMH) and inhibin B and ultrasonographic evaluations were performed on the third day of the menstrual cycle 1 year after the tubal sterilization procedure. ResultsMean blood estradiol, follicle stimulating hormone and luteinizing hormone levels on the third day of the cycle postoperative 12 months after the surgical intervention did not show any significant differences in the groups with respect to their age-matched controls. There was no significant difference in terms of mean serum AMH and inhibin B levels between the groups and their age-matched controls. However, significantly higher postoperative levels of mean AMH levels were detected in the tubal sterilization during cesarean section group when compared with the minilaparotomy group, and significantly lower postoperative levels of mean inhibin B were detected in the elective tubal sterilization via minilaparotomy group when compared with the cesarean section group. Statistically significant differences were observed in terms of number of antral follicles and mean ovarian volumes being less in the elective tubal sterilization via minilaparotomy group when compared with age-matched controls. ConclusionIntraoperative cesarean section tubal sterilization seems to be a practical and safe method, and has less effect on the ovarian reserve when compared with planned tubal sterilization by minilaparotomy.

Transvaginal Natural-Orifice Transluminal Endoscopic Surgery (NOTES) in Adnexal Procedures

From August 2010 to June 2011, 10 consecutive patients underwent transvaginal NOTES of the adnexa, including tubal sterilization in 3, salpingectomy because of ectopic pregnancy in 3, and ovarian tumor enucleation in 4. The mean (SD; 95% CI) age of the patients was 34.8 (9.7; 27.9–41.8) years, and their body mass index was 21.6 (2.8; 19.4–23.8). In 9 of the 10 patients, the procedure was completed. The 3 tubal sterilization procedures were completed in 18 to 30 minutes, with negligible blood loss. Operative time for the 3 salpingectomies because of ectopic pregnancy was 62 to 116 minutes. One of these procedures included management of 2000 mL hemoperitoneum. Three of the 4 attempts at ovarian enucleation were successfully completed within 64 to 162 minutes, with estimated blood loss ≤50 mL. One NOTES procedure failed because of a misdiagnosed peritoneal mucinous tumor located anterior to the uterus and inaccessible, leading to subsequent conversion to transabdominal laparoscopy. Our preliminary results show that purely transvaginal NOTES is feasible and safe for use in performing uterine adnexal procedures in selected patients. However, the procedure cannot be used in patients with cul-de-sac disease, and could have limited use in treating lesions located anterior to the uterus.

Postpartum intrauterine device insertion and postpartum tubal sterilization in the United States

The purpose of this study was to estimate US rates of postpartum intrauterine device (IUD) insertion and postpartum tubal sterilization. Data from the 2001-2008 Nationwide Inpatient Sample were used to identify delivery hospitalizations with IUD insertion or tubal sterilization procedure codes. Estimated rates of postpartum IUD insertion and postpartum tubal sterilization were 0.27 and 770.67 per 10,000 deliveries, respectively. Although the rate of IUD insertion was similar across age groups, the rate of tubal sterilization increased with age. Nonetheless, 15% of tubal sterilizations occurred among women who were ≤ 24 years old. IUD insertion was more likely among women who delivered at teaching hospitals (odds ratio, 3.02; 95% confidence interval, 1.43-6.37); tubal sterilization was more likely among women without private insurance (odds ratio, 2.04; 95% confidence interval, 1.97-2.11). Among US postpartum women, IUD insertion occurs considerably less frequently than tubal sterilization, even among younger women for whom poststerilization regret is a concern.

Evaluation of Ovarian Reserve Following Tubal Sterilization Using Anti-Müllerian Hormone

BACKGROUND: Tubal sterilization is among the most frequently used methods of contraception in the United States. Depending on the type of tubal sterilization procedure, the mesosalpingeal vascular arcade, a source of collateral ovarian blood flow, is variably interrupted. In women presenting for desired fertility after previous tubal sterilization, ovarian reserve is a critical determinant as to whether tubal anastamosis or in vitro fertilization represents the best treatment option for the couple.

Committee Opinion No. 458: Hysterosalpingography After Tubal Sterilization

The U.S. Food and Drug Administration has approved two devices for hysteroscopic tubal sterilization. To minimize the failure rates of these effective methods, it is important for health care providers to understand the important role hysterosalpingography (HSG) plays in any hysteroscopic tubal sterilization procedure. The purpose of this Committee Opinion is to emphasize the necessity of performing HSG 3 months after hysteroscopic tubal sterilization and to identify factors that may interfere with performance of an adequate HSG assessment.

Tubal ligation regret and related risk factors: findings from a case-control study in Pernambuco State, Brazil

A case-control study was carried out at a public teaching hospital in Recife, Pernambuco State, Brazil in 1997 to investigate risk factors among women who feel regret after undergoing sterilization through tubal ligation. The study compared sterilized women who had requested or undergone a tubal reversal with women who were also sterilized but had not undergone this surgery, nor had requested to do so. Women showing a significantly greater probability of regret were those sterilized at a young age, those who had not themselves made the decision to undergo surgery , those for whom the sterilization was carried out up to the 45th day after childbirth and those who had acquired knowledge about contraceptive methods after the tubal ligation procedure. Having had a deceased child, a partner with no children prior to the current union or a change of partner after the tubal sterilization procedure were also associated to the request for or submission to tubal sterilization reversal. It is necessary to assess women's psycho-socio-demographic profiles, their reasons for requesting tubal ligation and to advise the patient about family planning in order to reduce rates of post-sterilization regret.

Cost-Effectiveness Analysis Comparing the Essure Tubal Sterilization Procedure and Laparoscopic Tubal Sterilization

ObjectiveTo analyze the financial implications of establishing a hysteroscopic sterilization program using the Essure micro-insert tubal sterilization system in an ambulatory clinic. MethodsA retrospective cohort study (Canadian Task Force classification Type II-2), in an ambulatory women’s health clinic in a tertiary hospital, of 108 women undergoing Essure coil insertion between 2005 and 2006, and 104 women undergoing laparoscopic tubal sterilization for permanent sterilization between 2001 and 2004. The Essure procedures used a 4mm single channel operative hysteroscope and conscious sedation (fentanyl and midazolam); the laparoscopic tubal sterilizations were completed under general anaesthesia with a 7mm laparoscope and either bipolar cautery or Filshie clips. Costs associated with the procedure, follow-up, and management of any complications (including nursing, hospital charges, equipment, and disposables) were tabulated. ResultsThe Essure coils were successfully placed on the first attempt in 103 of 108 women (95%). Three patients required a second attempt to complete placement and two patients required laparoscopic tubal sterilization after an unsuccessful Essure. All 104 laparoscopic tubals were completed on the first attempt with no complications reported. The total cost for the 108 Essure procedures, including follow-up evaluation, was $138 996 or $1287 per case. The total cost associated with the 104 laparoscopic tubal sterilization procedures was $148 227 or $1398 per case. The incremental cost-effectiveness ratio was $111. ConclusionsThe Essure procedure in an ambulatory setting resulted in a statistically significant cost saving of $111 per sterilization procedure. Carrying out the Essure procedure in an ambulatory setting frees space in the operating room for other types of cases, improving access to care for more patients.

Simplification of laparoscopic tubal reversal by using a tubal cannulator

Approximately 1% of all patients who had tubal sterilization procedures will seek consultation for tubal reversal a few years after the operation (Liskin, 1985). We started doing laparoscopic tubal reversal (LTR) in 1998, in 2002 introduced the use of a tubal cannulator (TC) as part of the procedure. Our study compares all our LTR before and after the TC was introduced.