A 31-year-old woman has attended the clinic requesting reversal of sterilisation.
(a) What principles will underpin your management? (16 marks)
(b) How will you counsel her after the procedure?
Common mistakes
● Illogical in management – not following a logical order
● Describing the details of reversal of sterilisation – microsurgical or macrosurgical techniques; describing these in detail, etc.
● It is not offered in the National Health Service, hence she should be offered in vitro fertilisation (IVF)!
● Refer to the private sector for reversal
● Discussing the causes of tubal damage and how these can be prevented to avoid reversal
of sterilisation
● Commenting on the regret rate following sterilisation and discussing how this can be
minimised with appropriate counselling
● Listing the reasons why a reversal should be performed
● Highlighting the cost of reversal
A good answer will include some or all of these points
(a) What principles will underpin your management? (16 marks)
● The request needs to be justified (this is not a scientific concept)
● Information about the type of sterilisation (from history or from gynaecology notes if
patient cannot remember).
If notes are not available, request them – diathermy poor
success rate, clips or rings – good success rate
● Ovulating or not – investigate
● Semen analysis – normal?
● Assess Fallopian tubes at laparoscopy – what will be the length of Fallopian tube left after
reversal?
● If residual Fallopian tube is less than 4 cm, success rate is poor
● Type of reversal – microscopic or macroscopic
● Complications
● Alternatives to reversal of sterilisation if unaccepted
(b) How will you counsel her after the procedure? (4 marks)
● Pregnancy rates highest within the first 12 months of the procedure
● Increased risk of ectopic pregnancy – therefore to report if period missed or at the earliest positive pregnancy test
● Avoid the intrauterine contraceptive device (IUD) as a form of contraceptive for the
future
Sample answer
(a) What principles will underpin your management? (16 marks)
A request for reversal of sterilisation is not uncommon, especially as approximately 10 per cent
of women in the UK regret the decision to undergo sterilisation. In the first instance, this
request needs to be assessed to determine whether it is justified. For most units, there are strict
criteria that have to be fulfilled before a reversal can be allowed.
Following justification of the procedure, additional information is required about the type
of sterilisation the patient had. A laparoscopic sterilisation with clips offers the best success
rate of reversal, followed by sterilisation by rings. Open sterilisation, where portions of the
Fallopian tubes were excised, and diathermy sterilisation have poorer reversal success rates. If
she had diathermy sterilisation, the success rate is so poor that it might not even be advisable
to offer her a reversal.
Factors that could potentially affect the success rate of a reversal must be excluded. These
include ovulation and good quality semen. If any of these is abnormal, attempts have to be
made to identify the cause and to correct them before the reversal. Assessment of ovulation is
best done by serial luteal-phase progesterone assays, whereas a semen analysis will identify any
abnormal male factor.
If the decision is to offer a reversal, the next principle will be to determine how much residual Fallopian tube will be left after the procedure. This may be assessed at the time of the reversal or as a separate procedure. The advantage of making such an assessment as a separate
procedure is the opportunity it provides for the assessment of the pelvis for coexisting factors,
such as endometriosis or pelvic adhesions, which could affect fertility if not rectified. Some
surgeons believe that such a separate procedure exposes the patient to an unnecessary risk of
repeated general anaesthesia. However, there are others who believe that this separate assessment is important as it provides an opportunity for a prognostic assessment before surgery. If
the residual Fallopian tube is judged to be considerably less than 4 cm, it may not be worth
undertaking the procedure.
Where the patient is suitable for reversal, the success of the procedure will depend on the
type of reversal and the expertise of the operator. Microscopic reversal has a higher success
rate than macroscopic reversal. In addition, when performed by a skilled operator the procedure has a better success rate. In good hands, and by use of microsurgical techniques, the success rate is in the order of 70–80 per cent. Any complications (especially infections) arising
after the procedure will influence success. Attempts must therefore be made to maintain
meticulous asepsis and also to offer prophylactic antibiotics to minimise the risk of infection.
Where the request is unacceptable or is considered unsuitable, alternatives such as IVF with
embryo transfer should be discussed and offered if available.
(b) How will you counsel her after the procedure? (4 marks)
The success rate will also be influenced by the interval between the reversal and pregnancy. It
is highest within the first 12 months of surgery. This should be emphasised during the counselling offered before the reversal, as there is no benefit in undertaking the procedure if t
patient is uncertain about trying for a baby for at least 12 months. The risk of ectopic pregnancy is increased and the patient should be educated not only on the early warning symptoms
but also on the importance of seeking medical advice early following a missed period or an
early pregnancy test. The IUD is not advisable even when she has completed her family, as the
risk of ectopic pregnancy is also higher.
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