Laparoscopic reversal of sterilisation is not a new procedure. The first report of this procedure was published in medical literature in 1989

Female sterilization is the commonest permanent method of sterilization in the world. Most women having decided to be sterilized are happy with their decision. The commonest contributors to regret at being sterilized are

• Sterilization at a young age (under the age of 30)

• Pressure from partner

• Not in a stable relationship at the time of sterilization.
  

And with most things in life circumstances may change, and women may either decide to add to their existing family or may meet a new partner with whom they would like to start a family.

If and when this happens they need to decide between either IVF (in-vitro fertilization) or to have their sterilization reversed.

To both of these groups of women reversal of sterilization or IVF will not be available on the NHS so cost may be an issue.
Advantages of Laparoscopic sterilisation
One of the advantages of reversal of sterilization is the fact that if it is successful it can be used more than once at no extra cost.
Success rates
If women decide to have the sterilization reversed success rates are between 47-80% and will depend on:

1.     How the original sterilization was performed. 
This  determines the amount of tube available for the reversal. 

• The shorter the length of tube the less likely the reversal to be successful.  
• The commonest circumstance for this to be the case is if the original sterilization was carried out at Caesarean section.
  

2.    Age at time of reversal

•     The older you are at the time of reversal the lower the fertility rate.
  
•      Fertility generally decreases after the age of 35years
  
•      Over the age of 40 years, pregnancy rates fall and the rates of miscarriage and ectopic pregnancy increase.
  

3.     Any other pathology in the pelvis that may impair fertility

4.    Partners ability to make you pregnant

• This depends on partner’s semen analysis, which should be performed even if partner has children from a previous relationship.
  

Previously the gold standard was open surgery but nowadays reversal of sterilization can be carried out as a day case procedure in the majority of women provided they meet the criteria by laparoscopic keyhole surgery.

It has the advantage of using microsurgical techniques and the tubes are clearly visualized and handled with delicate instruments to improve success rates.

Pregnancy after reversal of sterilization

• The majority of women achieve pregnancy within a year of reversal.
  

• The advice is to try for pregnancy spontaneously if ovulation is not a problem otherwise your doctor may prescribe medication to aid ovulation (commonly clomid)
  

• If pregnancy is not achieved within 6 months you may be advised to have a test to check whether your fallopian tubes are still open. If they are continue to try spontaneously. 
  

• If your tubes are found to be blocked the next course of action may be IVF.
  

As with open surgery the main thing to look at after the reversal is the risk of ectopic pregnancy, which may be as high as 6%

Female sterilization remains the most effective way in terms of risk, of protecting against pregnancy.

It is the commonest method of permanent sterilization worldwide

It is only for women who have completed their families and are sure they do not want to have any more children.

Before being sterilized women need to be sure that they want a permanent potentially non-reversible method of contraception, and have explored alternative methods of contraception.

Alternative methods include

1.     The Mirena IUS. This method is as effective as being sterilized and it has the added advantage that it can be removed if and when pregnancy is desired.

a.     There is a small but negligible risk of pelvic infection. If this happens it usually does so within the first 10 days of insertion.

b.      And if there is no infection within this time it is unlikely to occur in women are in a monogamous relationship.

c.      Partners also have to be in a monogamous relationship.

2.     Implants. An example of this is Implanon. This is also an effective method of contraception. It is inserted in the upper inner arm under local anaesthetic

3.     Depot injections

4.     Contraceptive pills

5.     Vasectomy: it is important that there is a discussion with partners as male sterilization is a very effective way of sterilization in a monogamous relationship.

a.     comparing laparoscopic sterilisation  to vasectomy, with a vasectomy

                                               i.     Complications are 20 times less

                                              ii.     General anaesthetic is not required

                                            iii.     It costs about a third less to have a vasectomy

                                            iv.     It is less likely to fail than a sterilization (10-37% less likely)

Having explored these other options women may still opt to be sterilized.

The advantages over other methods would include

1.     It requires no motivation and women don’t need to remember to take pills

2.     It is permanent

3.     Compared to barrier methods of contraception you don’t have to reach for contraception before the event, so intercourse remains spontaneous

4.     Once done it doesn’t need to be replaced at intervals

There are however some disadvantages and drawbacks. These include

1.     The risk of failure which is put at about 1:250

2.     The risk of ectopic pregnancy

3.     It is potentially irreversible

a.     It is reversible but in the UK the reversing procedure is not available on the NHS

Sterilization is not a procedure that should be taken lightly as it may be associated with regret.

Regret is more common

1.     In young women under the age of 30

2.     Women who have no children

3.     Women who are not in a stable relationship

4.     Women who are put under pressure to be sterilized

The procedure of sterilization involves a general anaesthetic and a laparoscopy. Clips are used to obstruct the tubes It is done as a day case so expect to go home the same day.

Sterilization does not affect menstrual periods

Sterilization does not affect sex drive

The clips do not show up on airport x-rays

Other than a laparoscopic procedure it is now possible to be sterilized without the need of a laparoscope, without an anaesthetic. This is known as Hysteroscopic sterilization. During this procedure surgeons insert a titanium coil into each tube through the vagina into the uterus and into the fallopian tubes

This treatment is a safe and effective alternative to surgery for some women who suffer from symptoms related to uterine fibroids. This method of treatment that does not require an operation was first reported in 1996.

80% of women find relief of their symptoms, and the fibroids shrink by about 40% in volume.

It is less invasive than myomectomy or hysterectomy for the treatment of symptoms of fibroids, and in the short term it is associated with a shorter hospital stay and return to normal activities

Is it suitable for all fibroids?

It is best suited for fibroids that are located in the muscle of the womb. It is less suitable for fibroids that have developed stalks and are attached by these stalks to the uterus (pedunculated fibroids), as sometimes when this type of fibroid is deprived of blood supply by the embolization process, they may drop off onto bowel and become necrotic and cause complications.

Who performs the procedure?

Interventional radiologists perform the procedure.

How is the procedure performed?

A general anaesthetic is not required for this procedure. A catheter is inserted into the femoral artery (a major vessel in the groin area) after local has been used to numb the crease of the groin. X-ray guidance (fluoroscopy) is used to manipulate the catheter until it gets to the uterine artery (the major vessel that supplies the womb and the fibroids). The aim is to block off the blood supply to the fibroid. Once the blood supply of the fibroid has been identified special particles are used to effect blockage. The procedure usually takes the best part of 45 minutes.

After effects of the procedure

The procedure can be painful thus all women are usually given painkillers for the procedure.

After the procedure for a week or two women may have flu like symptoms (post-embolization syndrome) but these usually pass with the use of painkillers and anti-inflammatory agents. For this reason though the symptoms may regress in the first few days it is best to plan a week or maybe 2 off work

There may be a vaginal discharge, for the first few weeks, which also gets better over time but may persist in about 16% of women for up to a year.

Some women may notice that they pass one or more of their fibroids vaginally (fibroid expulsion). This is usually of little consequence, but if it still attached to the womb by a stalk and cannot detach itself, an additional procedure may be required to remove the fibroid this happens in about 6-10% of women and is  usually within 6 months of the procedure.

Embolisation can result in infection in about 0.5% of cases most of which settle with a course of antibiotics. In the extremis it can result in septicemia necessitating emergency hysterectomy as a life-saving procedure.

Embolization is contraindicated in women who have active pelvic infection

Pregnancy and embolization

As a general rule embolization is not recommended for women who want to get pregnant.

It is best for women who have completed their families and are looking for a non-surgical alternative to treat their fibroids.

Women who want to be pregnant after fibroid treatment should probably opt for a surgical procedure rather than embolization, as though it can be used in

women who are looking to get pregnant, the main drawback is the possibility of going into premature menopause which can happen in about 1-2% of women aged 40 years and under, and as many as 5% in women over the age of 45 years, reaching up to 15% by the age of 50years

Pregnancy after embolization can also be associated with:

Increased risk of miscarriage

Increased risk of bleeding after delivery

Increased risk of caesarean section

Increased risk of baby being in the wrong position

For these reason myomectomy remains a sensible option for women who want to get pregnant and if possible laparoscopic myomectomy is the best option.

Is the procedure effective?

Yes in a recent report by NICE (National Institute of Clinical Excellence) in 2010, they reported on a registry of 1387 women and found that symptoms related to fibroids were improved by 84% at 6 months and 83% at 24 months, with significant improvement in quality of life.

It can be expected that the fibroids will decrease in size by 40%

Is it as effective as myomectomy?

In relation to pregnancy it is not. A recent medical study that looked into this thought it was not superior to myomectomy they looked at 121 women treated with embolization they had a pregnancy rate of 50% compared to 78% in the myomectomy group.

Miscarriage rate was also more in the embolization group 64% compared to 23%

Looking at resolution of symptoms surgery is also superior to embolization at 1month and 12 months follow up

What are the down sides of having an embolization?

In one study up to 23% of women needed another intervention to control their symptoms either hysterectomy or repeat embolization another reported the rate to be 28% at 5 year follow up.

The chance of re-intervention increases the younger you are when you have the procedure.

Is it suitable for women who have had a failed surgical procedure for fibroids?

Yes it may be suitable but again for women who have completed their family.

Unfortunately there have been recent reports that it is more likely to fail in women who have had a previous myomectomy. However for this group of women it is a matter of weighing up risks and benefits. Usually if women have had a previous myomectomy particularly an “open” procedure, there is a 90% chance that there will be adhesions (scar tissue) in the abdomen. Of these adhesions 30% may be significant and increase the risk of complications for a repeat operation. Therefore for some women embolization may be a safer option.

Again this should be weighed up against the benefits of a repeat procedure for fibroids. In women who have had a previous open operation for fibroids the results for control of symptoms are not as good neither are fertility rates.

The likelihood of fibroid regrowth is 20-25% over 5 years.

Below is a powerpoint presentation to be used as an educational resource for women who have fibroids. It provides information to help women understand the process of decision making when it comes to the treatment of uterine fibroids

The above video is an educational video and contains actual surgery.
it demonstrates a multiple laparoscopic myomectomy being performed. it show the relatively bloodlessness of the procedure and how good surgical technique reduces the amount of adhesions formed by performing such surgery.
90% of women who have a myomectomy will develop adhesions of which a third of these adhesions will be significant and have consequences.
the use of anti-adhesive substances also reduces the amount and number of adhesions.
If you are about to have a myomectomy ask your doctors what will be done during the procedure to protect you from adhesions

Harry Reich performed the first laparoscopic hysterectomy in 1989. Since then it has grown in popularity.

The advantages of the laparoscopic approach to benign gynaecology is no longer in doubt and in common compared to other methods of hysterectomy it is associated with:

Less blood loss

Less requirement for pain relief

Shorter hospital stay

Quicker recovery

Quicker return to normal activity

Quicker return to family life and work.

The one thing that was in doubt was the higher complication rate.

A popular study published in 2004 put the complication rate for laparoscopic hysterectomy at 11%, which was the highest when compared to the traditional open abdominal hysterectomy and vaginal hysterectomy.

However the flaw in this study was the validation of the chosen participants and it could be argued that the surgeons chosen were great open and vaginal surgeons but their laparoscopic surgery was not so great.

An expert laparoscopic unit in Belgium a few years later published a series of nearly 4000 women and they had a complication rate of less than 1%.

The difference and success rates are down to skill acquired by the surgeon as well as the workload. The more procedures that are done by the surgeon the greater the success.

Despite the recognized advantages  and low complication rates in competent hands, most women still have the traditional open surgery when hysterectomy is required and usually the stumbling block is the training and choice of their surgeon

I often say to my patients sometimes these laparoscopic procedures may take longer to perform but in the long run the patients benefit from shorter hospital stay and quicker recovery.

Having said this it important to properly select patients for the right procedure.

The best hysterectomy in the absence of prolapse or cancer would be the laparoscopic subtotal hysterectomy with removal of the fallopian tubes and retention of the ovaries.

In women who have had abnormal cervical smears or pelvic pain with or without endometriosis  the laparoscopic total hysterectomy would be the best procedure.

For women with pelvic pain and endometriosis when a hysterectomy is required they may also benefit from a total laparoscopic hysterectomy as there are suggestions in medical literature that retaining the cervix may not be a good idea in women with pelvic pain. As if pain persists they may need a second procedure to remove the cervix.

References

EVALUATE hysterectomy trial: a multicentre randomised trial comparing abdominal, vaginal and laparoscopic methods of hysterectomy.

Garry R, Fountain J, Brown J, Manca A, Mason S, Sculpher M, Napp V, Bridgman S, Gray J, Lilford R.

A series of 3190 laparoscopic hysterectomies for benign disease from 1990 to 2006: evaluation of complications compared with vaginal and abdominal procedures

O Donnez*, P Jadoul, J Squifflet, J Donnez

below is an educational video of a total laparoscopic hysterectomy

A hysteroscopy is an investigation to examine the inside of the womb. It involves inserting a fine telescope into the vagina and passing it through the neck of the womb, to visualize the inside of the womb.

It allows the investigator to look for polyps or fibroids or abnormalities within the womb

Pelvic pain can be caused by a number of things that may not be gynaecological. For gynaecological reasons however, for women who have completed their families hysterectomy may be an option.

Gynaecological reasons for pelvic pain include

• Endometriosis
  

This is a condition where tissue that normally lines the cavity of the womb is found in other areas of the pelvis

• Adenomyosis
  

This is a condition where tissue that normally lines the cavity of the womb is found in the muscle of the womb.

Symptoms are usually pain during menstruation (dysmenorrhea) and heavy periods.

A good number of women who have endometriosis will also be found to have Adenomyosis

• Chronic pelvic inflammatory disease
  

About 10% of women who develop infection in the pelvis will go on to develop chronic pelvic pain.

Hysterectomy is not the first point of call for women with pelvic pain. It is important that women be properly investigated and alternative treatments considered before embarking on a hysterectomy particularly for pelvic pain.

Hysterectomy for Adenomyosis:

Adenomyosis is found in 20-30% of hysterectomy specimen. Though there are alternative treatments for Adenomyosis the overall failure rate is in the region of 20%.

Hysterectomy is superior to all other treatments for endometriosis.

Laparoscopic hysterectomy should be the ideal treatment choice.

Where possible the ovaries should be retained.

Because of the theoretical risk of persisting pain if there is also Adenomyosis in the cervix. The cervix is probably best removed at the same time.

In summary for Adenomyosis if hysterectomy is to be performed it is best carried out by the laparoscopic route the ovaries are best left behind but the cervix is best removed,


Hysterectomy for endometriosis


Hysterectomy is not the primary treatment for endometriosis. For women who have both endometriosis and Adenomyosis who have completed their families it is a good option for treatment of central pain.

Between 70-90% of women who have hysterectomy for pain symptoms of endometriosis will improve. For those who have pain during intercourse 60-70% will have some improvement.

Symptoms may recur in about 15% of women with between 3-8% requiring additional surgery

The laparoscopic route for hysterectomy is probably the best option.

If the ovaries are not involved in the endometriotic process they are best left behind.

It is important that if the ovaries are left behind that all visible pelvic endometriosis is removed.

If the ovaries need to be removed the majority of women will need to have Hormone replacement therapy.

There is a small risk that hormone replacement therapy may reactivate the endometriosis. this is usually in the region of about 1%

Women may also be advised to have the cervix removed.

The most important factor is removing all visible endometriosis as well as performing the hysterectomy.

• Hysterectomy for chronic PID
  

for women with chronic pelvic pain resulting from PID may improve after a hysterectomy. if the ovaries and tubes are involved with adhesions they are also best removed.
the laparoscopic hysterectomy is best for this group of women as it allows for adhesions to be broken down and the hysterectomy performed under visualisation.