|Year : 2021 | Volume
| Issue : 3 | Page : 232-235
Novel method of tuboplasty using a thread stent: possibility to increase the success rate
Anuradha Palnitkar, Devdatt Palnitkar
Palnitkar Hospital, Shriphal, Bhagyanagar, Aurangabad, Maharashtra, India
|Date of Submission||20-May-2021|
|Date of Acceptance||12-Jun-2021|
|Date of Web Publication||03-Sep-2021|
Dr. Devdatt Palnitkar
Consultant Surgeon and Urologist, Palnitkar Hospital, Shriphal, Bhagyanagar, Aurangabad 431001, Maharashtra.
Source of Support: None, Conflict of Interest: None
Background: Women who have undergone tubectomy for sterilization seek reversal of sterilization for various reasons. The success rate of the traditional method used for recanalization has been compared to our novel method of using a stent. Objective: The aim of this article is to evaluate the success rate of a novel method of tuboplasty using a threaded stent. Materials and Methods: Twenty-one tuboplasty surgeries for reversal of sterilization done at our center were reviewed. All the patients underwent open abdominal tuboplasty using 4× Loupes for magnification. 6-0 Prolene (Johnson & Johnson) suture was used for tubotubal anastomosis with seromuscular sutures. In 11 patients operated on after the year 2010, a 1-0 Ethilon (Johnson & Johnson) thread was used as a “stent.” Before the year 2010, we used to do the anastomosis similarly but without a stent. Eight such patients operated upon before 2010 without stent were evaluated. Two patients operated upon after 2010, in whom the stent could not be placed satisfactorily, were also included in this group of unstented patients. Results: Of the 11 patients who could be stented successfully, 8 (72.7%) conceived a uterine pregnancy. Two patients (18.2%) from the stented group did not conceive. From the group of patients who were not stented or could not be stented (n = 10), only two (20%) conceived. Conclusion: Our novel method of tuboplasty using a thread stent can improve the pregnancy rate to 72.7%.
Keywords: Novel method of open tuboplasty, reversal of sterilization, tuboplasty
|How to cite this article:|
Palnitkar A, Palnitkar D. Novel method of tuboplasty using a thread stent: possibility to increase the success rate. MGM J Med Sci 2021;8:232-5
|How to cite this URL:|
Palnitkar A, Palnitkar D. Novel method of tuboplasty using a thread stent: possibility to increase the success rate. MGM J Med Sci [serial online] 2021 [cited 2021 Sep 21];8:232-5. Available from: http://www.mgmjms.com/text.asp?2021/8/3/232/325536
| Introduction|| |
Tubectomy is the most common method of permanent sterilization in India. Jain and Muralidhar demonstrated that the female sterilization rate as a percentage of all contraceptive methods used rose from 34% in 1980–1984 to 42–43% in 1985–2005 in Asia. The National Family Health Survey (2005–2006) in India reported female sterilization as the common method of contraception preferred by 66% of women. Data from the USA noted female sterilization as the second most common method of contraception in all women; while it was the commonest among women aged above 35 years.
It is noteworthy that, in India, a tubectomy is the commonest method of permanent sterilization. Tubectomy is often done along with the cesarean section or after vaginal delivery. Tubectomy is done equally commonly by open method and by laparoscopy. However, the popularity and success of the tubectomy program largely depend on successful reversal when desired, besides easy access to and safety of the procedure.
Some women, for various reasons, wish to conceive again after undergoing a tubectomy. Operative reversal of tubectomy is possible by various methods of surgery depending on the setting. The most commonly employed method for reversal of tubectomy and recanalization is open tuboplasty. This method does not require a very advanced setup and can be carried out in most operation theaters.
The other methods of reversal of sterilization include microscopic tuboplasty and laparoscopic or robotic tuboplasty. Both these operative methods require an advanced operation theater setup, costly instruments, and a very high skill of surgical technique, which are not commonly available everywhere. If surgery is not possible for some reason or not desired by the patient, the alternative is in-vitro fertilization (IVF). This facility also may not be available in small towns and cities generally. The treatment of IVF is costly and can be taxing psychologically.
We have been following a simple but novel technique of tuboplasty that can be emulated in small nursing homes too and that leads to a higher success rate. In this study, we evaluated the success rate of the novel method of tuboplasty using a monofilament polyamide thread stent.
| Materials and methods|| |
In the study, 21 tuboplasty surgeries for reversal of sterilization done at our center by a couple of surgeons were reviewed for results. These were the patients who had followed up regularly in the post-operative period. The patients were between 27 and 38 years of age. Time since tubectomy varied from 1 to 10 years. All the patients underwent open abdominal tuboplasty. 6-0 Prolene (Johnson & Johnson) suture was used for tubotubal anastomosis with seromuscular sutures.
In 11 patients, a 1-0 monofilament polyamide Ethilon (Johnson & Johnson) thread was used as a “stent.” The thread was inserted in the fimbrial end, threaded across cut ends of the tube at the site of the previous tubectomy, and placed in the uterine cavity across cornu [Figure 1]. The abdominal end of the thread was brought out over the skin for future ease of removal. The tubotubal anastomosis was then done over this stent, which ensured patency of the lumen during and after anastomosis.
|Figure 1: Line diagram demonstrating use of Ethilon thread stent placement during tuboplasty|
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In two of the cases, it was not possible to pass the stent on either side into the uterine cavity. Passage of the stent across the anastomosis, into the uterine cavity, ensures that the thread would not come out accidentally during the procedure of anastomosis or the post-operative period. In the two cases in which the thread stent could not be passed into the uterine cavity, it was kept across the anastomosis as far into the proximal end of the tube as possible. Both these cases were analyzed as “not stented.”
The monofilament polyamide thread stent was removed in the outpatient clinic after 6 weeks. Two patients passed one thread each per vagina.
| Results|| |
Twenty-one women were included in the study. Stents were placed successfully in 11 women [Figure 2]. In both stented and not stented groups, the patients were comparable in terms of age (P = 0.829) and duration after tubectomy (P = 0.831) [Table 1].
Death of a male baby was the most common reason for seeking reversal in 90.5% of women (100% in stented and 80% in non-stented women), and the difference was not statistically significant (P = 0.11) [Figure 3]. The site of tubectomy was isthmic on both sides for 52.4% women (54.5% in stented and 50% in non-stented women), followed by isthmic-ampullary (n = 7) and ampullary on each side (n = 3) [Table 2].
Among stented women, the rate of uterine conception was 72.72, whereas among non-stented women, the success rate as measured by uterine conception was 20%. The sample size is very small and the difference in the rate of conception in these two groups was statistically significant (P = 0.015) [Figure 4]. One patient from the stented group had a tubal pregnancy and needed surgery for ruptured ectopic pregnancy. Ten patients were not able to conceive (one had separated from her husband). The set of patients who were not able to conceive included the two patients in whom the thread stent could not be negotiated into the uterine cavity on either side. All these patients who did not conceive had their tubes ligated very near the fibrial end, making a disparity in lumen between two cut ends of the tube difficult to anastomose [Figure 4].
| Discussion|| |
Indian women and families widely accept tubectomy as a method of permanent sterilization to limit family size. However, there are several reasons which may force them to seek reversal of tubectomy. In our study, the death of a male baby was the most common reason for seeking reversal of tubectomy. Jindal et al. reported that 64% of women wanted tubectomy reversal following the death of a male child. Similarly, Narvekar reported that death of one or more children was the most common cause for seeking tubectomy reversal among 67.8% of women.
The technique of tuboplasty is an important factor that determines its success rate. When it is performed macroscopically (the conventional way), the maximum success rate reported has been 50%. However, with the microsurgical technique (with a microscope), term pregnancy success rates of 46% and 56% have been reported. In this study, tuboplasty using a thread stent resulted in a successful pregnancy rate of 72.72%. Yassaee reported pregnancy success in 26.6% of women after tuboplasty.
The site of anastomosis is another important determinant of the success rate of tubectomy reversal. It is suggested that the isthmus of the fallopian tube is an ideal site for sterilization, considering the possible need for reversal., We could achieve 63.6% term pregnancies after bilateral isthmo-isthmic type (7 out of 11). Sapre et al. reported 55% term pregnancies after isthmo-isthmic and 40% after isthmo-ampullary anastomosis.
Among stented women, the rate of conception was 72.7%, whereas among non-stented women, the success rate was 20%.
The duration between tubectomy and tuboplasty is also another factor that affects success rate after reversal of sterilization. In our study, among those patients who conceived following tuboplasty, the mean duration after tuboplasty was 4 years. Brar et al. have reported a success rate of 70.5% if the duration between tubectomy and tuboplasty is less than a year. In our study, only one woman underwent tuboplasty within 1 year of tubectomy. She conceived and carried the pregnancy to term.
| Conclusion|| |
Our novel method of tuboplasty using a monofilament polyamide stent across anastomosis leads to a higher than previously reported success rate of pregnancy after surgery.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Institutional ethical clearance is not required as there is no significant alteration in the form of treatment. However, full informed consent of patients has been obtained for the surgical procedure as well as for collecting the clinical data for scientific publication.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]