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From 1976 through 1979, 740 women were referred to the author for potential tuboplasty; of these, 435 patients (58.8%) were selected for diagnostic laparoscopy. A tubal repair by laparotomy was performed on 280 patients, and 35 (12%) of them were pure bilateral implantations into the posterior uterine wall. The procedure was successful in 24 patients (68.6%).

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PIP: Focus in this discussion is on a "so-called" poststerilization syndrome as a result of laparoscopically performed sterilization. The study reported compared asymptomatic patients sterilized with a bipolar electrosurgical or Falope Ring laparoscopic technique with women having a hysterectomy and with controls. 4 groups of women were studied: patients sterilized with the bipolar electrocoagulation laparoscopic technique; patients sterilized with the Falope Ring laparoscopic method; women having had a hysterectomy with ovarian conservation; and normal control patients. Statistical methods employed included analysis of variance and the Studnet's t-test. 48 patients were evaluated in a total of 74 cycles. Onset of menses, or basal body temperature (BBT) drop for the hysterectomy patients, following serum sampling showed no significant deviation among the 4 groups. Although the control patients showed mean and median estradiol concentration values higher than those of the operated groups, the only statistically significant comparison was with the ring-sterilized patients. No statistical difference in progesterone concentration was demonstrable when the 4 groups were compared. All 13 electrically sterilized patients had hormonal assessment in 2 menstrual cycles. 9 of 12 control patients had 2-cycle sampling, permitting an analysis of individual cycle-to-cycle variation for these 2 groups. Only in the sterilized group is there significant correlation coefficient for estradiol. The other 3 comparisons show relationships that could be accounted for on a chance basis. The only statistical difference was a lower estradiol mean in ring patients as compared with controls. In sum, hysterectomy patients and women sterilized either by bipolar electrocoagulation on the occlusive-ring technique showed no change in midluteal progesterone levels as compared with control patients.^ieng

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PIP: Prior to undergoing conservative pelvic surgery for improvement of fertility, there must be meticulous preoperative evaluation. This evaluation involves a history, all previous records and operative reports, psychologic evaluation, physical examination, hysterosalpingogram, laparoscopy, and tests for male factor and ovulation. In history taking, the physician is most interested in past evidence of infection. The emotional status of the patient must be considered, especially for those individuals who are seeking sterilization reversal. Often, with a history of previous pelvic surgery the rate of success is lowered. Physical examination is usually not useful in predicting final outcome of microsurgery; however, it does determine the patient's general preoperative status. Hysterosalpingography and laparoscopy are complementary procedures which are the cornerstone of the preoperative evaluation. The 1st gives evidence of the status of the uterus and the tube proximal to the block, if 1 exists. If the block is in the isthmic portion, the hysterosalpingogram will indicate how much of the tube is patent next to the corpus. Preoperative laparoscopy is necessary for proper and complete evaluation of pelvic status; it allows the operator to visualize the distal segment of the tube. Laparoscopy indicates the extent of pelvic adhesion, ovary and tube involvement, mobility of the tube, extent of fimbrial involvement, and presence of disease. When all factors are taken are into consideration, the surgeon must determine whether the benefits of surgery will outweigh the risks. Patient age, emotional needs, other parameters of fertility, status of tubes and ovaries, etc. must all be taken into consideration.^ieng

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PIP: Microsurgery is a techniqe whereby visual acuity is increased through the use of a microscope or other optical magnifying device. Because of the delicate nature of this procedure, an experienced surgeon does not necessarily make a good microsurgeon. A good microsurgeon should be able to consistently reanastomose 1 to 2 mm vessels. The technique is learned through constant practice on laboratory animals. A special attitude and demeanor toward microsurgical techniques is also important for success. Microsurgery of the fallopian tube should be done only under special conditions, and using special microsurgical instruments and equipments. Before tubal plastic surgery is considered, 2 issues must first be resolved: 1) if there is any other cause for the infertility, and 2) if tubal plastic surgery is indicated for the patient at this time. Before tubal surgery is performed, the following conditions must be met: 1) semen analysis must be met, or couple must agree to artificial insemination using a donor; 2) female should have either spontaneous or induced ovulatory cycle; and 3) couple must understand possibility of failure, overall success rate, and sequelae of ectopic pregnancy. Couple must also agree to preoperative investigation of the tube. General tubal techniques include hysterosalpingography, laparoscopy, and hydrotubation. Also discussed are implantation, fimbriolysis, fimbrioplasty, and salpingostomy.^ieng

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Cases were reviewed in which both laparoscopy and ultrasound were performed for diagnostic purposes at the Ben Taub General Hospital, Houston, Texas, from January 1976 through May 1977. Thirty patients were found to have undergone both procedures. The most common reason (13 cases) was the presence of an adnexal mass. The findings from both techniques agreed in 20 cases, for a positive correlation of 66.7%. Different diagnoses were found in 10 cases, for a negative correlation of 33.3%. The major cause of the discrepancy was the presence of pelvic adhesive disease, not diagnosed by ultrasound but observed via laparoscopy. When the ultrasound findings were reported as "normal," all were confirmed at laparoscopy. Eight laparotomies were performed, and in each case the laparoscopic findings were confirmed.

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PIP: This article reports on 900 cases of laparoscopic sterilization by tubal ligation with a silastic band. There were no major complications, and laparotomy had to be performed only in a very few cases for bleeding. There were no pregnancies; the only real major problem was serious pain in 22% of patients. There were 4 cases of mesosalpinx hematoma, a minor complication not requiring surgical intervention. Although it has been reported that the silastic ring can be lost in the abdomen, such a problem did not happen in this series. There were a few misapplications of the ring, immediately corrected. There were no problems with the ring itself, and no cases of infection. The operator should be very skilled and well acquainted with the equipment and with every part of the procedure. More time will be required to determine the effectiveness of this method of sterilization.^ieng

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A method was developed to alter surgically the bursa of the bitch to allow sequential observation of the ovary by means of laparoscopy. Adult anesthetized female dogs of three breeds underwent laparoscopic examinations in which each natural bursa slit was lengthened 1.0-1.5 cm using laparoscopic hook scissors in conjunction with electrocautery. The ovary could be effectively and repeatedly exposed for laparoscopic viewing through the lengthened bursa slit. Neither laparoscopic surgery nor frequent routine laparoscopic examinations of the reproductive organs had an effect on subsequent ovarian activity. All dogs subjected to the laparoscopic ovarian exposure technique exhibited estrus behavior, follicle development, ovulation and corpus luteum formation. Preovulatory follicular development was detected as early as 11 days before ovulation with the most rapid follicular maturation occurring two to three days before ovulation. Follicular collapse and extensive hemorrhage at the rupture site during ovulation did not occur. Release of the cumulus mass from a vesicular follicle was observed in one bitch. The cumulative mass adhered to the follicular wall for an indefinite time following ovulation. The structural size of the bitch corpus luteum was maximal four to eight days following ovulation. Corpora lutea remained visible on the ovarian surface for 16 weeks. No differences in cyclic ovarian morphology were observed among the three breeds of dogs studied.

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PIP: The laparoscope is a long, thin tube with a light source and an optical system. Ancillary instruments can allow a physician to perform procedures through the same incision, or sometimes a second incision. After distending the abdomen with gas, a sheath is inserted into the abdomen, and the telescope is placed within the sheath. Laparoscopy can be used for diagnostic purposes as well as surgical, and the most common operation performed is tubal ligation for sterilization. Other operative procedures that can be performed with the laparoscope are removal of adhesions or foreign bodies, drainage of cysts, and burning or elimination of small amounts of endometriosis. Postoperative effects include reactions to the gas or bloody discharge following a D&C. Properly used, laparoscopy has a great deal to offer patients and their physicians as an uncomplicated approach to diagnosis and/or therapy.^ieng

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In an attempt to avoid the serious complications of electrosurgical sterilization via laparoscopy, specially designed applicators have been used to apply a silastic band to the fallopian tube, thereby occluding it. Two hundred and eighty cases have been performed, 70 of which have been followed for more than 1 year. There have been no pregnancies. The technic is relatively simple. Complications result when the tube is excessively thickened, when the tube is fixed in position by adhesion, or when the tube is grasped too close to the cornua or too rapidly. These complications have been relatively few and can be easily avoided.

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