This service provided by the Reproductive Science Centerª of the San Francisco Bay Area
The use of the operating microscope first began about 1921. In the 1960's, ophthalmology, otorhinolaryngology (ear, nose and throat) and plastic surgery had become firmly committed to the operating microscope. The early 1970's revealed the preliminary uses of microsurgery in the field of urology and gynecology. Significant advances in the late 70's have enabled the microsurgeon to correct problems which up to then were considered incurable.
Microsurgery must be performed by specialists in their field who have had advanced training in microsurgical techniques and procedures. Microsurgery should be practiced by the specialist who has progressed satisfactorily from animal microsurgery to, eventually, microsurgical procedures in the human patient. The attempt to do microsurgery without extensive training is usually catastrophic.
We perform all MTR procedures at our office-based AAAHC accredited surgical facility, as an ambulatory (out-patient) procedure, and are the least expensive program offering tubal reversal in the Bay Area. Our published success (pregnancy) rates are among the highest of any program.
Not all hospitals have an operating-room microscope. This special instrument allows the surgeon and his assistant to look through powerful lenses while doing the surgery. Visualization and lighting are greatly enhanced. Tiny instruments, smaller needles and sutures all result in less tissue damage and consequently decreased scar tissue formation.
Microsurgery requires the basic understanding of tubal physiology. It also requires meticulous hemostasis (control of bleeding), extremely gentle tissue handling, precise dissection, and exact approximation of tissue planes.
Before a patient undergoes a microsurgical procedure, she and her husband should have completed an infertility workup. This may include a diagnostic laparoscopy to determine the length of the tube remaining on each side.
Microsurgical techniques are now being used with increased success for accurate anastomosis of the fallopian tube. The average time between reversal surgery and pregnancy is 10 months. Results do depend on the type of prior sterilization done. Those with minimal tissue damage (such as Hulka clips, the Falope Ring, the Pomeroy method and a single burn bipolar method) are most favorable for reversal. If a fimbriectomy has been done or a large portion of the tube has been removed, reversal efforts are usually futile. In Vitro Fertilization techniques then are the only and best approach for pregnancy.
Results of tubal microsurgery vary. After reviewing the data of many good studies, the following intrauterine pregnancy rated can be expected:
a. Salpingostomy (depending upon extent of pathology) 25-30%
b. Uterotubal anastomosis (reconnect tubes to uterus) 30-50%
c. Tubal reanastomosis (prior sterilization procedure) 80-90%
The following are some of the contraindications to microsurgery:
1. A "frozen pelvis." This occurs when pelvic adhesions are so dense that normal pelvic anatomy cannot be restored.
2. The high-risk surgical patient.
3. Existing pelvic infection.
4. Emergency laparotomy (not the time to perform delicate type of surgery).
5. The inexperienced surgeon (the first reconstructive attempt yields the best results).
The following are some of the indications for microsurgery:
1. Microsurgical lysis (cutting) of adhesions, such as salpingolysis (cutting tubal adhesions) and ovariolysis (cutting ovarian adhesions. The use of microsurgical technique and the use of micro-instruments helps to prevent further post-operative adhesions.
2. Fimbrioplasty, microsurgery on the terminal part of the tube.
3. Salpingostomy, opening the tube previously diseased and closed.
4. Tubal anastomosis, excising the diseased portions of the tube and rejoining healthy tubal segments.
5. Tubal cornual (or uterotubal) anastomosis, putting the tube directly into the cornual aspect of the uterus.
6. Tubal reanastomosis, rejoining of tubes which have been cut during a prior sterilization procedure.
The lists of indications continues to grow as our research in microsurgical techniques and experience increases. Microsurgery is a dynamic field. Success rates are changing from year to year. As procedures and techniques improve, so will the success rates.
Copyright 2000-2011 Donald I. Galen, M.D., FACOG
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