relations to fertility and childbea...

relations to fertility and childbearing can be erect in literature from as early as 800 BCE when Hindu physicians first discussed the universal of uterine tubes.(1) In the mid-1500s, Gabriele Fallopius, an Italian anatomist, published the first correct description of the uterine tube.(2) Fallopian tube surgery first was performed in 1884(3) and on 1924, surgeons had begun performing tubal interruption (ie, sterilization) procedures(4) Today, fallopian tube interruption is the same of the most common forms of contraception in the United States.(5)

A significant portion of women who bear these procedures are in their twenties and thirties.(6) For a variety of reasons (eg change in marital status, wish for additional children, death of children, religious matters psychological factors), many of these women later ask restoration of fertility through tubal anastomosis procedures(7) The most numerous common reason for requesting restoration of tubal patency is change in marital status.(8) A research published in 1986 reported that 10% of the six million American women who had undergone tubal interruption transactions regretted the decision and that 1% beged surgical reversal procedures to restore fertility.(9)

FALLOPIAN TUBE ANATOMY

The fallopian tubes originate at the upper portion of the uterus just beneath the uterine fundus. They reach forth approximately 11 cm (4.3 in), curving up and athwart the ovaries. Each fallopian tube is approximately 1 cm (04 in) in diameter and flares disclosed like the bell of a blazon at its ovarian end. The widened cessation is fringed with finger-like projections called fimbriae, which put in motion and create currents that draw ova into the wide period of the fallopian tube. The horn-like region that is closest to the uterus is the cornual region of the fallopian tube, and the narrow region near the uterus is the isthmus. The widest portion of the tube is the ampulla, which is where fertilization usually flash on the minds (Figure 1).(10)

[Figure 1 ILLUSTRATION OMITTED]

TUBAL INTERRUPTION METHODS

Surgeon use a variety of techniques to achieve completed interruption of the fallopian tubes. These [i]modus operandi[/i]s include

* the Pomeroy and modified Irving techniques, in which a portion of the tube between the isthmus and ampulla is removed;

* fimbriectomy (ie, excision of the widened closes of each fallopian tube);

* cornual resection (ie, resection of a small portion of the hornlike region closest to the uterus, leaving the tranquillity of fallopian tube undisturbed); and

* application of spring clips or silicone bands as mechanical alternatives to electrosurgical coagulation and resection techniques.(11) The amount of tubal damage caused through the interruption procedure is a determining factor in a woman's candidacy for a reversal procedure

MICROSURGICAL REVERSAL PROCEDURES

The disentanglement of microsurgical techniques has revolutionized surgical reconstruction of fallopian tubes. Microsurgical tubal anastomosis permits atraumatic, accurate alignment of fallopian tube sections The reconstructed fallopian tubes are shorter in longitudinal dimensions but almost normal in other respects(12) Using microscopes, surgeon can extract scar tissue while conserving maximum tubal fulness Microscopes also provide illumination of surgical sites and provide surgeon unobstructed views of dissection planes, thus decreasing disruption of normal tissue.(13) An additional advantage of using microscopes in tubal anastomosis transactions is the ability to have the direction of bleeding and minimize damage to surrounding structures(14) Using fresh microsurgical anastomosis techniques, surgeons are able to restore fertility in the majority of women who meet with reversal procedures (ie, pregnancy rates of 60% to 80% can be achieved).(15)

Surgeon use a variety of microsurgical techniques to anastomose fallopian tube sections The most commonly used system entails a combined laparoscopy and minilaparotomy with microsurgical repair of the fallopian tube.(16) Another approach consists of laparoscopy, hysteroscopy and laser-assisted preparation of the tubal parts for anastomosis.(17) A third approach consists of a minilaparotomy with microsurgical repair of the tube (ie, no preliminary laparoscopy is performed).

At the Naval Hospital Camp Pendleton, Oceanside, Calif, we use the third mode if we have sufficient information about a woman's tubal section lengths. If these data are not available, we use the first system (ie, combined laparoscopy, minilaparotomy, microsurgical repair).

PATENT SELECTION

special patient selection is essential to help achieve prosperous fertility outcomes. The preoperative evaluation involves several grades which include

* a patient interview to explain the nature, size and implications of the planned surgical procedure;

* a patient medical record review to document previous surgical processs and routine fertility evaluations of the woman and her partner (ie, ovulation documentation on measurement of biphasic basal material substance temperature and progesterone levels; seed analysis to ensure presence of motile sperm) to make secure the greatest chance for postoperative conception;