Research

 
Dr. Hanafi has had several medical studies published:
 
“Ultrasound diagnosis of adenomyosis, leiomyoma, or combined with histopathological correlation.”
Journal of Human Reproductive Sciences. Volume 6, Issue 3, November 2013. Click here to access the full text.
 
“Comparative study between robotic laparoscopic myomectomy and abdominal myomectomy.”
Middle East Fertility Society Journal. October 2013. Click here to access the full text.
 
“Predictors of leiomyoma recurrence after myomectomy.”
Obstetrics and gynecology. Volume 105, Issue 4, April 2005.
 
“Factors affecting the pregnancy rate after microsurgical reversal of tubal ligation.”
Fertility and Sterility. Volume 80, Issue 2, August 2003.
 
Dr. Hanafi published a medical study paper, “Factors Affecting the Reproductive Outcome after Microsurgical Tubal Reversal”.It was published in the August 2003 issue of Fertility and Sterility journal. This study was made up of 128 patients that had tubal reversal performed by Dr. Hanafi between October 1992 and May 2001.

The average age of these patients was 33, but they ranged in age from 22 to 46. Several months after surgery, 88% of the patients had at least one verifiably open tube, and 86% of these had a subsequent pregnancy. The overall pregnancy rate in the patients followed after surgery was 75%.

Factors affecting Pregnancy Rate (PR)
There was no statistically significant difference in PR between the methods of tubal sterilization (tied, burned or clamped).

Age was a significant factor, and it had the strongest association with the pregnancy rate when compared with the other factors. The PR decreased considerably as patient age increased; it was 96% in patients 30 years old or younger, 80% in patients 31-35 years, and 45% in patients older than 35 years.

The advancement of age is linked to a reduction in the ovarian reserve function, in the quality of the ova, and in the sexual function. There is also an inreased risk of diseases with age advancement; among these are gynecological conditions such as fibroid tumors and menstrual irregularities, which can have some bearing on the PR after tubal reversal surgery.

If you are considering tubal reversal surgery, it is important to try to have the procedure sooner rather than later. This will help maximize your chances for pregnancy by minimizing the age effect that has been demonstrated by this study and others. However, 25% of the patients 42-44 years of age did conceive after tubal reversal.

Body Mass Index (BMI) was also a significant factor on the PR, with the PR diminishing gradually as BMI increased. The PR was 85% for BMI of 25 or less (normal), 73% for BMI 26-29 (overweight), and 59% for BMI 30 or over (obese). To determine your BMI, see the chart in the article titled ?Weight Control – Eating Right and Keeping Fit? on the GYN & Fertility Specialists home page.

Being overweight is associated with hormonal changes and with low sexual function because of negative body image. If your BMI is over 25, you should try to reduce your weight to improve your chances for pregnancy. The weight factor can be modified, although not easily, by dieting and exercise before and after reversal surgery.

Duration of sterilization was a significant factor; the PR by number of years after tubal ligation was 91% for 1-5 years, 81% for 6-10 years, 72% for 11-15 years, and 22% for 16-20 years. There was a moderate correlation between age and number of years sterilized, which likely had some effect on these results. However, even after controlling for age, there was a higher PR in those sterilized 5 years or less.

Conclusions
Age was the dominant significant factor affecting pregnancy rate in tubal reversal patients. Body mass index and duration of sterilization had smaller, but statistically significant, associations with PR.

If you are interested in getting a complete manuscript of this study, please contact the office and we will provide you with one.


Factors affecting the pregnancy rate after tubal ligation reversal

Magdi M. Hanafi, M.D.

Saint Joseph’s Hospital Of Atlanta.

Objective:  To evaluate the factors affecting the reproductive outcome after tubal reversal.

Design:  Retrospective clinical study.

Setting:  Tertiary care center.

Patients:  104 patients were evaluated for microsurgical reversal of previous tubal ligation, during the 64-month period from January 1995 to May 2001.  Pregnancy outcome was analyzed in 63 patients whom we were able to follow for a minimum of 6 months.

Factors considered:

1) Age.

2) Body Mass Index (BMI).

3) Concurrent hysteroscopy for menorrhagia.

4) Concurrent myomectomy.

5) Type of tubal ligation.

6) Post-operative hysterosalpingogram (HSG) result.

Results:  The overall pregnancy rate (PR) was 76.2% in the 63 patients with sufficient follow up, and the intrauterine pregnancy (IUP) rate was 74.6%.  Five patients had an ectopic pregnancy after their surgery, and four of these also had an IUP.  The PR was 91.2% in patients at or below the median age of 32 (n=34), and it was 58.6% in patients over 32 years of age (n=29).  The patients at or below the median BMI of 25 had a PR of 83.9% (n=31), while those above the median BMI had a PR of 68.8% (n=32).  The PR was 80.0% in patients that did not have concurrent hysteroscopy (n=35); it was 71.4% for those with hysteroscopy (n=28).  The PR in patients without concurrent myomectomy was 81.0% (n=42) versus 66.7% (n=21) in patients with myomectomy.  The pregnancy rates by method of tubal ligation were 73.0% (n=37) for Pomeroy, 72.7% (n=11) for rings/clips, and 90.0% (n=10) for cautery.  Twenty-three patients had a post-operative HSG, with a result of bilateral patency in 15 (65.2%) and unilateral patency in eight (34.8%).  Sixty percent of the patients with bilateral patency and 50.0% of the patients with unilateral patency became pregnant, compared with 87.5% (37/40) of the patients without an HSG.  Fifteen patients were not pregnant at the end of the follow up period; 10 of these had an HSG showing tubal patency on one or both sides.  Fifty-seven patients (90.5%) had either an IUP or an HSG result showing patency on at least one side.  The remaining six patients, including one with an ectopic pregnancy, elected not to have an HSG to assess tubal patency.

Conclusions:  (1) There was a strong association between age and PR, and a moderate association between BMI and PR.  Further consideration of these factors may be warranted in order to inform the patient of her chances for a successful pregnancy after tubal reversal.  (2)  The PR was insignificantly higher in patients with bilateral versus unilateral tubal patency, and it was significantly higher in patients that chose not to have an HSG.  (3) There was little or no evidence of a significant association between PR and myomectomy, hysteroscopy, or method of tubal ligation.

Key Words:  Tubal sterilization, microsurgical tubal reanastomosis, pregnancy rate, factors affecting the pregnancy rate.

When a patient makes the decision to have the surgical procedure of tubal ligation, she is responding to a particular set of social, financial, and emotional circumstances in her life.  These circumstances can change over the years, and it has been reported that up to 15% of patients having tubal ligation eventually regret their sterilization (7).  In this study, the most commonly reported reason for requesting tubal ligation reversal was divorce and remarriage; other reasons included change of heart and death of a child.  A patient should know her chances for a successful pregnancy if she has tubal reversal surgery, and she should know the factors that affect the PR.  The effect of the following factors has been evaluated in this study:  age, BMI, concurrent hysteroscopy, concurrent myomectomy, type of previous tubal ligation, and post-tubal reversal HSG result.

MATERIALS AND METHODS

Patients

One hundred four women had tubal reversal surgery performed by the author at Saint Joseph’s Hospital of Atlanta after January 1, 1995.  The office computer provided a list of all tuboplasty cases from January 1995 through May 2001, and the patients’ charts were reviewed.  The majority (56.7%) of patients had their tubal ligation by the Pomeroy technique, followed by ring or clip at 18.3%, and cautery at 14.4%.  At the time of their tubal ligation, the patients had a mean (± SD) age of 25.4 (± 4.2) years.  Eighty-three percent of the patients were younger than age 30, and 48% were younger than age 25, at the time of their sterilization.  The mean gravidity was 3.2 (± 1.4), with a minimum of one pregnancy and a maximum of seven pregnancies.  The mean parity was 2.5 (±1.1), which is typical for women in the United States.  Minimum parity was zero and maximum parity was six.  More than 95% of patients seeking tubal reversal surgery were new patients referred to the office specifically for this procedure.  Of 51 patients who provided a reason for requesting tubal reversal, 78.4% indicated their desire to conceive a child with a new partner.

At the time of tubal reversal, the mean age for these 104 patients was 34.0 (± 4.7) years.  The mean BMI was 27.8 (± 6.1).  Forty-five patients (43.3%) had hysteroscopy for menorrhagia concurrent with their tubal reversal, and 34 (32.7%) patients had concurrent myomectomy.  The mean duration of sterilization was 8.6 (± 4.3) years.  There was a moderate positive correlation between age at reversal and the number of years since sterilization (r = 0.564).

Before surgery all patients had transvaginal pelvic ultrasound in the office for evaluation of the pelvic organs, which included measuring the uterus and the proximal segment of the fallopian tubes, observing endometrial shape and thickness, and noting the presence of any fibroid tumors or ovarian cysts.  Hormonal evaluation was performed to assess the ovarian function for patients who were over 40 years old or who had any signs or symptoms of ovarian dysfunction (e.g. ogliomenorrhea, premenopausal symptoms, or a history of difficulty in getting pregnant before their tubal ligation surgery).

Operative Procedure

Patients were bowel cleaned by the use of two laxative tablets 24 hours before surgery and a Fleet enema 12 hours before surgery.  The aim of the bowel preparation is to minimize the gas pain following the surgical procedure and subsequently to reduce the duration of the hospital stay.  All of the patients received prophylactic antibiotics one hour before surgery consisting of two grams of Cefoxitin IVPB (or Doxycyclin 100 mg IVPB if
patients are allergic to penicillin).  All cases were done under general anesthesia.

The patient was placed in lithotomy position with her legs in Allen stirrups.  A size ten Foley catheter was placed in the uterine cavity and the balloon was inflated with 3-4 cc of saline.  The end of the catheter was attached to the drapes of the right leg.  Indigo Carmine, in a concentration of 5cc in 200cc of saline, was injected through the intrauterine catheter to check the patency of the proximal portion of the tube and the patency of the whole tube after completion of each reanastomosis.  A three-inch pfannenstiel incision was made.  Using Contravis operating microscope, microsurgical Gerald forceps and tenotomy scissors, and Vital-Vue Yankauer Tip for irrigation, the distal and proximal segments of the tube were approximated by suturing the attached mesosalpinx with 6-0 RB-1 half-circle needle polyglactin (vicryl) continuous suture.

The reanastomosis was performed in two layers by the use of 8-0  TG 140-8 polyglactin (vicryl) sutures.  The first layer (muscularis) was sutured mostly by 4-7 interrupted sutures starting at 6 o’clock and ending at 12 o’clock.  In some cases, there was a discrepancy between the diameter of the opening of the distal segment, which was larger, and that of the proximal segment.  Technically, the suturing of the muscularis layer was performed by taking larger suture bites transversally alongside the opening of the distal segment, and much smaller and closer suture bites longitudinally in the proximal segment.  The second layer (sero-muscular) was sutured in a continuous fashion with locking of each suture by using 8-0 TG 140-8 polyglactin (vicryl) sutures.  The skin was closed by 4-0 Dexon suture in a straight Keith needle.  Injecting 20cc of bupivacaine (Marcaine) 0.5% with epinephrine 1:200,000 under the skin has reduced the severity of post-operative pain and the dose and frequency of post-operative pain medications used.  The patient was given a full liquid diet after surgery and a soft diet as tolerated in the first post-operative day.  She was kept in the hospital for one to two days, depending on her medical condition and her desire in the first post-operative day.  She was seen in the office in one, three, and six weeks as post-operative follow up.  Patients were encouraged to have hysterosalpingogram (HSG) three to six months after surgery, unless pregnancy was already accomplished.

Statistical Analysis

Comparative pregnancy rates were analyzed with the chi-squared test, Fisher’s exact test, and logistic regression for the following factors:  age, BMI, concurrent hysteroscopy, concurrent myomectomy, type of previous tubal ligation, and post-operative HSG result.  Time intervals from surgery to pregnancy were compared using Student’s t-test.  A 95% confidence interval under the standard normal distribution was constructed to estimate the pregnancy rate for all 104 patients in this study.

RESULTS

The cases with insufficient follow up data were contacted via letter or phone call to request information about any subsequent pregnancies.  Ultimately, 63 patients were followed for a minimum of 6 months (range 6 to 68 months).  The median follow up period was 22 months.  The characteristics of the followed cases, in terms of the factors being evaluated, were comparable to those of all 104 patients in the study population (p > 0.2000) (Figure 1A & 1B).

The pregnancy rate was 76.2% in the 63 followed patients, and this statistic was used to construct a confidence interval estimating the PR in all 104 tubal reversal patients.  At the 95% confidence level, this estimated PR falls between 65.7% and 86.7%.  Thirty-two patients (50.8%) delivered babies and seven patients (11.1%) were currently pregnant when their follow up was completed.  Fourteen had miscarriages, and six of these also had successful pregnancies.  Five patients had an ectopic pregnancy, and four of these also had intrauterine pregnancies (Table 1).  Thirteen patients had more than one pregnancy after their tubal reversal.  Table 2 shows the pregnancy outcomes for the first subsequent pregnancy and the outcomes for all pregnancies (68 pregnancies among 48 patients).
 
Table 1:  Pregnancy Result in 63 Followed Patients

No. of Patients Percentage
Pregnancy 48 76.2
Intrauterine Pregnancy (IUP) 47 74.6
Ectopic Pregnancy 5 7.9*

*This figure includes four patients who had a successful pregnancy in addition to their ectopic pregnancy.
 
Table 2:  Outcomes for 48 Pregnant Patients

First pregnancy All pregnancies
Number Percentage Number Percentage
Intrauterine 45/48 93.8 63/68 92.6
Miscarriage 12/45 26.7 22/63 34.9*
Delivery 26/45 57.8 34/63 54.0
Ongoing Pregnancy 7/45 15.6 7/63 11.1
Ectopic 3/48 6.3 5/68 7.4

*This figure includes one patient who had five miscarriages, four patients who had two miscarriages, and nine patients who had one miscarriage.
 
The cumulative PR in the 63 followed patients was 55.6% at 12 months after surgery, 68.3% at 24 months, and 73.0% at 36 months.  By 24 months, the PR began to level off, but it continued to increase through 39 months (Figure 2).  Of 48 pregnant patients, 72.9% achieved their first post-operative pregnancy within 12 months, and 89.6% were pregnant by 18 months after surgery.  The median interval from tubal reversal surgery to first subsequent pregnancy was five months (range 0-38 months).
 
Table 3:  Patients with and without Pregnancy

Pregnant (n=48) Not Pregnant (n=15)
Characteristics:
Mean Age 32.3 (± 3.5) 37.1 (± 4.6)
Mean BMI 26.6 (± 5.6) 29.3 (± 7.0)
Procedure: No. of Patients (%) No. of Patients (%)
Myomectomy 15 (31.3) 6 (40.0)
Hysteroscopy 21 (43.8) 7 (46.7)
Pomeroy 27 (56.3) 10 (66.7)
Ring/Clip 8 (16.7) 3 (20.0)
Cautery 9 (18.8) 1 (6.7)

 

Factors affecting Pregnancy Rate:

Table 3 describes the characteristics of the pregnant patients compared with the patients that were not pregnant when their follow-up was completed.  The mean age was lower in the pregnant patients; the difference was significant (p=0.0014).  The mean BMI was lower in the pregnant patients, but the difference was not significant (p=0.1879).

Cases were divided into groups according to the patient’s age at the time of surgery, and the PR was calculated for each group.  The PR decreased considerably as age increased (Figure 3).  The PR was 91.2% in patients at or below the median age of 32 (n=34) and 58.6% in patients over 32 years of age (n=29).  The probability is less than 0.003 that the two rates would have differed this much or more by chance, if the PR were not associated with age (Table 4).  This provides strong evidence that the PR was significantly associated with patient age.  The younger age group had 7.3 times higher odds of pregnancy, compared with the older group (95% CI 1.8 to 29.5).  The mean interval from surgery to pregnancy was 8.7 (± 9.4) months for the younger group and 12.2 (± 11.5) months for the older group; the difference was not statistically significant (p=0.1946).

The PR diminished gradually as BMI increased (Figure 4).  There were only two patients with BMI less than 20 (15 and 17), and both became pregnant.  The PR was 83.9% in patients at or below the median BMI of 25 (n=31), and 68.8% in patients with BMI over 25 (n=32).  The probability is about 13% that the association would have been this strong or stronger, due to coincidence (Table 4); this probability is not statistically significant. The patients in the lower BMI group had a mean interval of 7.4 (± 7.7) months from surgery to pregnancy, and the corresponding interval for the higher BMI group was 13.0 (± 12.0) months; the difference was significant (p=0.0316).  While the median BMI was initially chosen as an objective cut point, the decrease in PR actually appears to begin at a BMI of 23 with these 63 patients.  Of seven patients with a BMI of 23, only four became pregnant.  The PR for patients with a BMI less than or equal to 22 was 93.8% (15/16), while those with a BMI greater than 22 had a PR of 70.2% (33/47).  The probability of observing a difference this great or greater is about five percent (p=0.0509), which provides some evidence of a negative association between BMI and PR.  The odds of pregnancy, for BMI ? 22 compared with BMI > 22, was 6.4, although a 95% CI did contain 1 (0.8 to 52.9).  There was a small correlation between BMI and age (correlation coefficient = 0.2589).

The PR in patients without concurrent myomectomy was 81.0% (34/42) versus 66.7% (14/21) in patients with myomectomy (Figure 5).  Twenty-eight of 35 patients (80.0%), who did not have concurrent hysteroscopy, were pregnant; the PR was 71.4% (20/28) for those with concurrent hysteroscopy (Figure 6).  The pregnancy rates by method of tubal ligation were 73.0% (27/37) for Pomeroy, 72.7% (8/11) for rings/clips, and 90.0% (9/10) for cautery (Figure 7).  Five cases did not specify method of tubal ligation.  The differences in PR according to myomectomy, hysteroscopy, and method of tubal ligation were not significant (Table 4).

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Tubal Patency

Patients that were not yet pregnant were encouraged to have an HSG three to six months after surgery.  At three months, there were 47 patients not pregnant, and by six months 37 patients remained not pregnant.  Twenty three patients agreed to have an HSG to evaluate their tubal patency; fifteen (65.2%) showed bilateral patency and eight (34.8%) showed unilateral patency.  While the proportion of patients having concurrent myomectomy or hysteroscopy was higher in the group with unilateral patency, the difference was not statistically significant for the given sample sizes (p>0.4300).  Likewise, the distribution of tubal ligation methods was similar between the two groups (p>0.4800) (Figure 9).  Of the sixteen followed patients that did not have an intrauterine pregnancy, 10 elected to have an HSG (6 bilateral patency; 4 unilateral patency).  Anatomical success of tubal reversal, on at least one side, was shown in 57/63 (90.5%) patients, either by HSG result or by intrauterine pregnancy.

__________________________________________________________________________________________

The PR was 60.0% (9/15) in the group with bilateral patency, and 50.0%  (4/8) in the group with unilateral patency; this difference was not significant (Table 4).  However the PR was 87.5% (35/40) in patients that did not have an HSG (Figure 8).  This was significantly different from the combined rate of 56.5% in patients with an HSG (p=0.0266).  The difference can be explained by the fact that the patients choosing to have an HSG were the ones that had been unsuccessful in achieving pregnancy thus far.  The patients with an HSG did not differ significantly in age from the patients without an HSG; the mean (± SD) age of the HSG group was 34.2 (± 4.3), versus 32.9 (± 4.2) for the group without HSG (p=0.2501).  The average BMI was different between the two groups, which is likely due to the aforementioned longer interval from surgery to pregnancy in the patients with higher BMI.    The mean BMI was 29.7 (± 6.5) for the patients having HSG, and it was 25.8 (± 5.3) for those not having HSG (p=0.0190).

Some conditions can make patency difficult to determine from the HSG results.  Uneven resistance between the two sides can cause the dye to flow more freely from one tube, even if the other tube is not obstructed.  Spasms can also contribute to an inability to note any spillage from one or both tubes.  In these situations, the HSG result will be inconclusive.  Of the eight patients with unilateral patency, five had unclear results on the other side.  One of the remaining three patients had a definite obstruction on the other side; another patient had her HSG subsequent to an ectopic pregnancy on the other side, and the third patient had only one side reversed.

Only two of the patients with ectopic pregnancy had an HSG to check tubal patency.  One of these cases had an HSG that showed the right side patent and the left side possibly obstructed.  Ectopic later resulted on the left side after four miscarriages.  The other case had an HSG after her ectopic pregnancy, which showed her remaining tube to be open.  The other three cases with ectopic pregnancy did not have an HSG, but they did have successful pregnancies after their reversal surgery.

P1 = Fisher’s exact test: p-value for the same or a stronger association       P2 = Pearson’s chi squared test:  two sided p-value

OR = Logistic regression:  odds ratio
CI = 95% confidence interval for odds ratio

Interval = Mean interval to pregnancy (months)

Table 4:  Explanatory Variables and PR, Interval to Pregnancy

Pregnant (%)             P1                        P2                        OR                           CI                                 Interval

Age

? 32                               31/34  (91)           0.0029                  0.0025                  7.3                        1.8 to 29.5                       8.7 (±   9.4)

> 32                               17/29  (59)                                                                                                                                         12.2 (± 11.5)

? 35                               41/47  (87)           0.0011                  0.0004                  8.8                        2.4 to 32.5

> 35                                 7/16  (44)

BMI

? 22                               15/16  (94)           0.0509                  0.0562                  6.4                        0.8 to 52.9                       8.0 (±   8.4)

> 22                               33/47  (70)                                                                                                                                         10.9 (± 10.9)

? 25                               26/31  (84)           0.1327                  0.1589                  2.4                        0.7 to 8.0                         7.4 (±   7.7)

> 25                               22/32  (69)                                                                                                                                         13.0 (± 12.0)

Pregnant (%)             P1                        P2                        OR                          CI                        Interval

Myomectomy

Without                        34/42  (81)           0.9396                  0.2095                  2.1                        0.6 to 7.0                         9.6 (± 10.7)

With                              14/21  (67)                                                                                                                                         10.9 (±   9.3)

Hysteroscopy

Without                        28/35  (80)           0.3088                  0.4274                  1.6                        0.5 to 5.1                         9.5 (± 10.2)

With                              20/28  (71)                                                                                                                                         10.6 (± 10.5)

Sterilization Type

Ring/Clip                        8/11  (73)           0.6657                  0.9872                  1.0                        0.2 to 4.6                       10.8 (± 12.9)

Pomeroy                       27/37  (73)                                                                                                                                         8.7 (±   8.6)

Cautery                           9/10  (90)           0.2491                  0.2592                  0.3                        0.0 to 2.7                       10.3 (±   9.7)

Pomeroy                       27/37

Ring/Clip                        8/11                    0.3308                  0.3141                  0.3                        0.0 to 3.5

Cautery                           9/10

HSG Result

Bilateral                          9/15  (60)           0.8163                  0.6450                  1.5                        0.3 to 8.4                       13.1 (± 11.9)

Unilateral                        4/8     (50)                                                                                                                                        17.6 (± 13.7)
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DISCUSSION

Tubal reversal by microsurgery is a viable option for the patient who has had tubal ligation and desires another child; another option is the in vitro fertilization (IVF) procedure.  The patient should know the options available for her, and the factors that affect the pregnancy rate.  This retrospective study evaluated 104 consecutive cases of tubal reversal microsurgery done by one surgeon, who has been performing microsurgery since 1979.  The surgeon’s experience was not considered as a factor in this study.  After a diligent effort to contact all patients, the PR was analyzed according to six explanatory variables, in 63 patients who were followed for a minimum of 6 months.  The characteristics of the followed cases were comparable to those of the 104 patients in the study population.  Therefore, it is reasonable to construct a confidence interval to estimate the IUP rate for all 104 patients who had the surgery.  We can be 95% confident that the IUP rate is between 63.9% and 85.4% for these 104 patients.  This interval is consistent with post-tubal reversal PR’s reported in the literature.

Rouzi et al. (12) reported that increasing age was a significant factor in reducing pregnancy outcome after tubal reversal surgery in 217 cases.  In spite of the smaller number of cases, this study found a similar relationship.  This is most likely caused by reduced ovarian reserve function and the quality of the ova by age.  Reduction of the sexual function with the advancement of age may also play a role in this equation.  The ovarian reserve test was not done in this study.  Only FSH and Estradiol were tested for the patients who were over 40 years old, or who were under 40 with abnormal hormonal symptoms.  In a future study, I will test the ovarian reserve in all ages before tubal reversal surgery and evaluate its correlation with the PR result.  There is an increased risk of diseases with age advancement; among these are gynecological conditions such as fibroid tumors and menstrual irregularities, which can have some bearing on the PR after tubal reversal surgery.  It is very important to encourage patients who are seeking tubal reversal surgery, to have the procedure sooner rather than later.  This will help maximize the PR result by minimizing the age effect that has been demonstrated by this study and others.

BMI had a smaller influence on the pregnancy rate result after tubal reversal surgery than the age variable.  However, we should encourage the patient to reduce her weight if her BMI is 25 or over, to improve her chances for pregnancy.  The reduction in the PR result in patients with a high BMI may be due to the hormonal changes associated with being overweight, and to low sexual function because of negative body image.

The effects of concurrent myomectomy and hysteroscopy were not statistically significant; nevertheless, patients that had these procedures did have a slightly lower PR.  Patients with myomectomy concurrent with their tubal reversal surgery had a 14% lower PR result.  This may be caused by the scar in the uterus, or by the fact that the remaining myometrium was abnormal or had lower blood flow as a result of the myomectomy.  Patients with concurrent hysteroscopy had a 9% lower PR result after surgery.  This is attributable to the underlying cause, rather than to the effect of the hysteroscopy surgery itself.

Pelvic transvaginal ultrasound before tubal reversal surgery is necessary for evaluation of the myometrium and endometrium, especially for those patients who have menstrual abnormalities.  This will allow the gynecologist to give the appropriate surgery recommendation to the patient; subsequently, all the procedures will be performed at one setting, which is more convenient to the patient physically, emotionally and financially.

Kim et al. (3), in a large series of 1,118 patients, reported that the pregnancy rate after microsurgical reversal was not significantly correlated with the method and duration of sterilization, the operative procedure, or the post-operative tubal length.  This study supports the conclusion that the type of tubal sterilization does not have a statistically significant association with the PR result after reversal surgery.  Post-operative tubal length and duration of sterilization were not evaluated in this study.

Post-operative hysterosalpingogram (HSG) can be helpful for determining the patency of the tubes after tubal reversal surgery.  Furthermore, flushing the tubes with water-soluble dye can break any possible fine adhesion in or around the suture line of the tube; consequently HSG can be therapeutic as well.  Transvaginal salpingosonography (TSSG) using air may be an alternative reliable, inexpensive method of assessing the patency after tubal reversal surgery (Spalding et al., 1998).

In conclusion, age affected the PR result significantly.  A prompt decision by the patient and the gynecologist performing the surgery is recommended to improve the PR result.  BMI had a moderate effect on the PR.  The weight factor can be modified, although not easily, by dieting and exercise before and after reversal surgery, to improve the PR result.  Post-operative HSG can be very helpful not only as a diagnostic, but also for a possible therapeutic purpose.  Method of tubal ligation, and concurrent hysteroscopy or myomectomy, had little or no influence on the PR result.

REFERENCES

1.  Voorhis BJ.  Comparison of tubal ligation reversal procedures.  Clinical Obstetrics and Gynecology.  2000;        Volume 43, Number 3, pp. 641-649.

2.  Yoon TK, Sung HR, Kang HG, Cha SH, Lee CN, Cha KY.  Laparoscopic tubal anastomosis:  fertility       outcome in 202 cases.  Fertil Steril.  1999; Volume 72, Number 6, pp. 1121-1126.

3.  Kim SH, Moon SY, Shin CJ, Lee JY, Kim JG, Chan YS.  Microsurgical reversal of tubal sterilization:  a     report on 1,118 cases.  Fertil Steril.  1997; Volume 68, Number 5, pp. 865-870.

4.  Fischer RJ.  Loupe microsurgical tubal sterilization reversal:  experience at a community-level naval       hospital.  The Journal of Reproductive Medicine.  1996; Volume 41, Number 11, pp. 855-859.

5.  Mettler L, Ibrahim M, Lehmann-Willenbrock E, Schmutzler A.  Pelviscopic reversal of tubal sterilization      with the one- to two-stitch technique.  The Journal of the American Association of Gynecologic    Laparoscopists.  2001; Volume 8, Number 3, pp. 353-358.

6.  Cha SH, Lee MH, Kim JH, Lee CN, Yoon TK, Cha KY.  Fertility outcome after tubal anastomosis by       laparoscopy and laparotomy.  The Journal of the American Association of Gynecologic Laparoscopists.    2001; Volume 8, Number 3, pp. 348-352.

7.  Cohen MA, Chang PL, Uhler M, Legro R, Sauer MV, Lindheim SR.  Clinical assisted reproduction:    reproductive outcome after sterilization reversal in women of advanced reproductive age.  Journal of   Assisted Reproduction and Genetics.  1999; Volume 16, Number 8, pp. 402-404.

8.  Spalding H, Perala J, Martikainen H, Tekay A, Jouppila P.  Assessing tubal patency with transvaginal    salpingosonography after the reversal of tubal ligation for female sterilization.  Human Reproduction.  1998; Volume 13, Number 10, pp. 2819-2822.

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12.  Rouzi AA, Mackinnon M, MeComb PF.  Predictors of success of reversal of sterilization.  Fertil Steril.     1995;64:29-36.

13. Gomel V. Microsurgical reversal of female sterilization: a re-appraisal. Fertil Steril 1980; 33:587-97.

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For reprints:  Magdi Hanafi, M.D., 1100 Lake Hearn Drive, Suite 480, Atlanta, Georgia 30342.  Email MHANAFI@aol.com.  Phone (888) 851-9060 or (404) 851-9300.  FAX (404) 851-1358.