From conception vs last menstrual period

The average duration of pregnancy is 38 weeks (266 days) from conception. Predicting the pregnancy due date based on conception is the most accurate way to calculate one’s due date, but usually the date of conception is not known. Therefore, the due date is generally calculated from the first day of the last menstrual period (LMP). In this case, 2 weeks are added to the calculation giving a total of 40 weeks (280 days). This is based on the assumption that ovulation/conception occurs on cycle day 14 in the “average” 28 day menstrual cycle.

From ovulation

Calculating the due date from LMP is subject to error since ovulation varies in its timing from the onset of menstruation among different women and from cycle to cycle. Many of Dr. Monteith’s tubal reversal patients know their date of ovulation from using an ovulation predictor kit (OPK) or keeping a basal body temperature (BBT) chart. Calculating the pregnancy due date from ovulation is more accurate than from the last menstrual period.

Our pregnancy due date calculator gives you the option of determining your due date from either the date of ovulation or the date of LMP. You can choose either of these dates in the calculator below.

Reliability of due date

The pregnancy due date is an simply an estimate of when pregnancy is at term and labor will begin. It is reasonably accurate within + or – 2 weeks. Labor begins on the calculated due date, however, in only a small percentage of cases.

Monitor your early pregnancy

The best way to monitor early pregnancy is with quantitative serum HCG assays. In a normally developing pregnancy, serum HCG levels double approximately every 2.5 days. You can use our HCG doubling time calculator and HCG graph to keep track of your serum HCG test results during the first 2 or 3 weeks after your missed period and positive pregnancy test. When serum HCG reaches 1500, we recommmend a vaginal ultrasound examination. By that time, a gestation sac should be visible in the uterine cavity.

Part of Dr. Monteith’s long term follow-up care after your tubal reversal is following your early pregnancy along with you and your local physician. To enable us to do this, please submit your completed pregnancy report form as soon as you have a positive home pregnancy test.

Pregnancy Information

• Pregnancy Signs and Symptoms – in collaboration with the American Pregnancy Association.
• Pregnancy Tests – detect the presence of the hormone human chorionic gonadotropin (hCG).
• Calculate your pregnancy due date – from ovulation or last menstrual period.
• Pregnancy Report Form – Send this when you have a positive pregnancy test.
• Birth Report Form – Send this when you have your baby after tubal reversal.
• Early Pregnancy Monitoring – Why tubal reversal patients require this!
• Weekly TR Pregnancy Report – Forum on the Tubal Reversal Message Board.
• Pregnancy Announcements – weekly updates from Dr. Monteith’s tubal reversal patients.

The post Pregnancy Due Date appeared first on A Personal Choice.

Parkland tubal ligation

Parkland Tubal Ligation

The Parkland tubal ligation technique falls into the category of tubal ligation and resection. The Parkland procedure involves tying two non-absorbable ligatures around the fallopian tube in its proximal to middle segment and then cutting out the tubal segment between the ligatures.

The end result is similar to the Pomeroy method of tubal ligation. Two healthy tubal segments remain that can be rejoined by tubal reversal microsurgery.

Two-thirds of women with a Parkland tubal ligation become pregnant following tubal reversal surgery.

Irving tubal ligation

Irving Tubal Ligation

Tubal ligation by the Irving method starts by placing two ligatures around the fallopian tube in its proximal to mid-segment and removing the tubal segment between the two ligatures. Then, the tied end of the segment of fallopian tube attached to the uterus is sutured into the back side of the uterus, and the other tied end is buried in the connective tissue underlying the fallopian tube.

As with other ligation/resection methods, the Irving technique leaves behind two healthy tubal segments that can be put back together with tubal reversal microsurgery.

The pregnancy rate after reversal of an Irving tubal ligation is 60-70%.

Tubal ligation procedures

Normal fallopian tube anatomy and other tubal ligation procedures described in the following pages are:

• Pomeroy Tubal Ligation
• Tubal Rings and Clips
• Monopolar and Bipolar Tubal Coagulation
• Parkland and Irving Procedures
• Fimbriectomy
• Essure and Adiana (Hysteroscopic Procedures)

The post Tubal Ligation and Resection appeared first on A Personal Choice.

Fimbriectomy tubal ligation

Fimbriectomy

Tubal ligation by fimbriectomy involves removing a portion (usually up to one-third) of the fallopian tube closest to the ovary. With microsurgical techniques, the end of the remaining fallopian tube can be opened and the inner tubal lining gently folded outward over the cuff to improve the chances of egg capture. This tubal reversal procedure is called microsurgical salpingostomy.

Reversing Fimbriectomy tubal ligation

Final Result

It is generally thought that tubal reversal cannot be successful following a fimbriectomy because of the loss of the important egg-capturing fimbria. Fortunately, the inner lining of the remaining tube also has the cilia that help transport the egg into and down the tube once it has been reopened. Cilia are particularly abundant in the ampullary portion of the fallopian tube. The length of the remaining tube and presence or absence of its ampullary segment can be determined by x-ray (hysterosalpingogram). This is recommended prior to undergoing a salpingostomy procedure. The pregnancy rate after fimbriectomy tubal reversal is 30-40%.

Tubal ligation procedures

Normal fallopian tube anatomy and other tubal ligation procedures described in the following pages are:

• Pomeroy Tubal Ligation
• Tubal Rings and Clips
• Monopolar and Bipolar Tubal Coagulation
• Parkland and Irving Procedures
• Fimbriectomy
• Essure and Adiana (Hysteroscopic Procedures)

The post Tubal Ligation – Fimbriectomy appeared first on A Personal Choice.

Essure Sterilization Procedure

Essure sterilization is a new hysteroscopic tubal occlusion method that became approved for use in the United States in November 2002.

Essure is a coiled spring device that is inserted through the uterine cavity into the tubal openings using a hysteroscope. This can be done as an office procedure. The Essure micro-insert consists of a stainless steel inner coil, a super-elastic outer coil, and polyethylene fibers wound in and around the inner coil. When released, the outer coil expands to anchor the micro-insert in the fallopian tube. As the device expands to fill the tubal opening, it gradually becomes scarred in place and forms a barrier so that sperm cannot reach the egg. The device extends from the uterine cavity, through the interstitial segment of the tube within the uterine muscle, and into the isthmic segment of the fallopian tube outside of the uterus. A hysterosalpingogram (HSG) is performed three months later to ensure the fallopian tubes are completely blocked and that the woman can begin relying on Essure to prevent pregnancy. Because of the scar formation, reversal of Essure can not be achieved by simply removing the coils. To reverse the Essure method of tubal sterilization, the fallopian tube must be cut beyond the reach of the Essure device and then implanted into a new opening in the uterus.

Adiana Sterilization Procedure

Adiana is another new hysteroscopic sterilization procedure. It was approved for use in the US by the FDA in July 2009. Adiana uses radio frequency energy and a polymer microsinsert that together result in tubal blockage in the interstitial segment of the fallopian tube that is within the uterine muscle.

With the Adiana procedure, a catheter is positioned immediately inside the opening of the patient’s fallopian tube using a hysteroscope. The catheter applies low-level radiofrequency (RF) energy to remove the thin layer of cells that line a 1 cm section of the inside of the fallopian tube. A soft polymer matrix implant, that is smaller than a grain of rice, is then inserted into the tubal opening. As scar tissue grows into the inplant, tubal blockage occurs. The area of the tube that is affected is smaller than with the Essure device. The portion of the tube outside the uterus is not affected. Similar to Essure, a confirmatory hysterosalpingogram (HSG) is performed three months later to ensure the fallopian tubes are completely blocked and that the woman can begin relying on Adiana for permanent contraception. Adiana reversal is also performed by the technique of tubouterine implantation.

Tubal ligation procedures

Common types of tubal ligation procedures include:

• Pomeroy Tubal Ligation
• Tubal Rings and Clips
• Monopolar and Bipolar Tubal Coagulation
• Parkland and Irving Procedures
• Fimbriectomy
• Essure and Adiana (Hysteroscopic Procedures)

The post Essure and Adiana Tubal Sterilization appeared first on A Personal Choice.

Tubal rings and tubal clips are mechanical methods of tubal ligation applied to the fallopian tubes through a laparoscope. Tubal rings and clips damage minimal lengths of the fallopian tube and are ideal for tubal reversal.

Tubal ligation with tubal rings

Tubal Ring

The tubal ring (also called the Falope ring, Yoon ring, or Lay loop) is a small silastic band placed around a loop of the fallopian tube. With this method of tubal ligation, a 2-3 cm segment of fallopian tube is drawn inside a narrow cone-shaped applicator. The silastic ring (that previously has been stretched over the outside of the applicator) is then released onto the tubal loop. As the ring contracts due to its elasticity, it constricts the base of the loop and blocks the fallopian tube. Deprived of its blood supply, the constricted loop is replaced with scar tissue, and the remaining healthy tubal segments separate, similar to the Pomeroy tubal ligation method. The pregnancy rate is 65% at one year following reversal of tubal ring procedures and continues to rise with the passage of time.

Tubal ligation with tubal clips

Tubal Clip

The spring clip or Hulka Clip (developed in Chapel Hill, North Carolina by Dr. Jaroslav Hulka) also causes mechanical obstruction of the fallopian tube. When open, the hinged clip made of plastic with a gold spring lock, is placed across the narrow muscular or isthmic segment of the fallopian tube close to the uterus. When the clip is compressed, the spring locks the clip tightly across the tube. Because of its narrow width (7 mm), the tubal clip damages the least amount of fallopian tube of any tubal ligation method. Another tubal clip is the Filshie clip that is made of titanium and silastic. The pregnancy rate is 76% at one year following reversal of tubal clip procedures and continues to rise with the passage of time.

Tubal ligation procedures

Normal fallopian tube anatomy and other tubal ligation procedures described in the following pages are:

• Pomeroy Tubal Ligation
• Tubal Rings and Clips
• Monopolar and Bipolar Tubal Coagulation
• Parkland and Irving Procedures
• Fimbriectomy
• Essure and Adiana (Hysteroscopic Procedures)

The post Tubal Ligation – Tubal Ring or Clip appeared first on A Personal Choice.

Pomeroy Tubal Ligation

Tubal ligation and resection (removal) of a portion of the fallopian tube is the most frequent method of blocking the tubes. This involves tying a segment of tube and removing it. There are many variations of this technique. The tubal ligation procedure described by Dr. Ralph Pomeroy a century ago is most commonly used today.

With the Pomeroy method of tubal ligation, part of the tube is elevated to create a loop or knuckle (top picture). An absorbable ligature is tied around the base of the elevated segment, and the tubal segment is cut out (middle picture).

Tied and Cut

Within a few days, the peritoneum (tissue that lines the organs of the abdominal cavity) grows over and covers the cut ends of the tubal segments. The cut ends of the fallopian tube separate as the ligature dissolves. The peritoneal covering and separation of the remaining tubal segments prevent them from re-attaching to each other (bottom picture).

Doctors like the Pomeroy procedure because it is simple and effective. Pomeroy tubal ligation is most often performed after delivery by cesarean section.

Pomeroy tubal ligation typically leaves two healthy segments of fallopian tube that can be rejoined through tubal ligation reversal surgery. The amount of tube removed can be determined prior to tubal reversal from the tubal ligation operative report and pathology report. If you have your doctor or hospital send us these reports, Dr. Monteith will review them and let you know what your prognosis for pregnancy will be after tubal reversal.

Final Result

Variations of the Pomeroy tubal ligation technique include the length and location of the tied and cut tubal segment, number and type of ligatures placed around the tube, and whether the cut ends of the tube were also crushed or coagulated. These variations of the Pomeroy procedure determine the lengths of tubal segments remaining that can be repaired. The Pomeroy method of tubal ligation is a good one to have if you are considering tubal reversal surgery. Approximately two-thirds of women with a Pomeroy tubal ligation become pregnant following tubal ligation reversal.

Tubal ligation procedures

Normal fallopian tube anatomy and other tubal ligation procedures described in the following pages are:

• Pomeroy Tubal Ligation
• Tubal Rings and Clips
• Monopolar and Bipolar Tubal Coagulation
• Parkland and Irving Procedures
• Fimbriectomy
• Essure and Adiana (Hysteroscopic Procedures)

The post Tubal Ligation – Pomeroy Technique appeared first on A Personal Choice.

Essure sterilization is intended to be permanent, but with our expertise Essure does not have to be permanent and pregnancy is possible. We were the first doctors in the world to publish successful reports of full term pregnancies after surgical reversal of both Essure and Adiana sterilization procedures.^1-2

Since our initial reports we have performed over one hundred and twenty-nine (129) outpatient surgeries to correct these newer types of tubal ligation procedures.

What Is Essure?
A brief overview

Essure coils in place

During an Essure procedure a small metal coil is placed inside the opening of each fallopian tube. This causes the tube to heal closed by the formation of scar tissue around the coil and inside the tube. This blockage only occurs in the very beginning of the fallopian tubes.

The Adiana procedure is similar to, but not as common as, Essure sterilization. Adiana has been removed from the market and is no longer being performed.

Removing Essure coils
Our statistics

From January 2008 to January 2014, we performed one hundred and twenty nine (129) Essure and Adiana corrective surgeries. Of this group, one hundred and twenty five (125) women had tubal blockage from Essure sterilization and four (4) had blockage from Adiana sterilization.

Of the 125 patients who underwent surgery to correct Essure and Adiana, 92 of these women had reversal to become pregnant. All surgeries were performed as outpatient procedures at our specialty center.

Of the 92 women who had reversal surgery, 68 have had 12 months or more to conceive. Of these 68 women, 24 have reported pregnancy. The pregnancy rate after reversal of Essure or Adiana at our center is 35.3%.

There have been a total of 17 separate patients who reported a total of 17 births after reversal of Essure

One patient had a vaginal birth. The other 16 underwent elective C-section, per our recommendation, to minimize the risk of pregnancy complications.

Readers are encouraged to view: Comments from our Essure reversal patients.

Risks of Essure reversal: Our statistics

One patient had unexplained abdominal pain 72 hours after reversal and underwent a laparoscopy by her local doctor with normal post surgical findings. She subsequently became pregnant and delivered a healthy baby (our first Essure reversal baby). None of our patients reported ectopic pregnancy or uterine rupture as delayed complications after Essure reversal.

Tubouterine implantation has been the historical gold standard for reversal of proximal tubal occlusion but has also been associated with an increased risk of uterine rupture during labor.^3,4,5 For maximal safety of both mother and baby, we advise our Essure reversal patients to have a scheduled cesarean delivery with future pregnancies to minimize the possible risk of uterine rupture during labor.

Our experience demonstrates outpatient reversal of Essure at our center is safe.

We are getting better at reversing Essure!

Our initial Essure pregnancy analysis in early 2013 suggested the pregnancy rate was 29% after reversal.

With more follow-up time we have seen the chance of pregnancy after reversal of Essure increase to 35.3%.

With a larger number of Essure patients we have also been able to identify specific surgical techniques which are more likely to result in pregnancy for our patients.

We are definitely seeing improvement.

IVF or Essure reversal

The chance of pregnancy after Essure reversal at our center is 35.3%. The chance of pregnancy after in-vitro fertilization (IVF) is approximately 36.8 % for each cycle attempted.⁶

There is no data to suggest what the success rate of IVF is when the Essure coils are allowed to remain; however, several case reports do exist of successful IVF with Essure coils left in place.^7,8

If the Essure coils project into the uterine cavity this may decrease the success of IVF and may increase the risks of a pregnancy complication. There are no studies to suggest what the success rate of IVF is when the coils are left in place. Limited  studies exists suggesting minimal risks to pregnancy in women who become pregnant after Essure failure or with IVF.^9,10

A single cycle of IVF costs approximately $12,000 to $14,000.

Costs of Essure reversal

For more information about the cost of Essure reversal, please visit: Essure reversal cost.

If you have any questions about Essure reversal or Essure coil removal then please call and speak with one of our nurses for a free Essure reversal consultation  at (919) 968-4656.

Readers are also welcome to ask Dr. Monteith questions by submitting them through our Ask The Doctor section of our website.

Reference

1. Normal pregnancy after outpatient tubouterine implantation in patient with Adiana sterilization. Monteith CW, Berger GS. Fertility Sterility 2011;Jul 96(1) 45-6.

2. Successful Pregnancies After Removal of Intratubal Microinserts. Monteith CW, Berger GS. Obstet Gyncecol 2012;119:470-472.

3. Uterine rupture following tubal reimplantation. Review of the literature and report of three additional cases. Shortle B, Jewelewicz R. Obstet Gynecology Surv 1984 Jul;39(7):407-15.

4. Uterine rupture after tubal reimplantation. Horovitz J et al, J Gynecol Obstet Biol Reprod (Paris) 1988;17(5):650-2.

5. Uterine rupture after re-implantation of fallopian tubes. Brandt CA, Larsen B. Acta Obstet Gynecol Scand 1989;68(3):281-2.

6. 2010 Assisted Reproductive Technology Report. Centers for Disease Control and Prevention. 2010 National Report.

7. Successful pregnancy outcome with the use of in vitro fertilization after Essure hysteroscopic sterilization. Kerin JF, Cattanach S. Fertility Sterility 2007; May 87(5) 1212.

8. Essure multicenter off-label treatment for hydrosalpinx before in vitro fertilization. Galen DI, Khan N, Richter KS. J Minim Invasive Gynecol 2011; May-June;18(3):338-42.

9. Outcomes of Pregnancies in Women with Hysteroscopically Placed Micro-Inserts In Situ. Veersema S et al, J Minim Invasive Gynecol 2013; Oct Suppl.

10. Essure for management of hydrosalpinx prior to in vitro fertilisation- a systematic review and pooled analysis. Arora P, Arora R, Cahill D, BJOG 2014; Jan 3.

The post Essure Reversal SurgeryStatistics Update appeared first on A Personal Choice.

From January 2008 to January 2014, we performed one hundred and twenty-nine (129) tubal surgeries to correct Essure and Adiana sterilization. Of the 129 women who sought treatment from our center, one hundred and twenty-five (125) had tubal blockage from Essure sterilization and four (4) had blockage from Adiana sterilization.

Can you remove Essure devices?

Removing Essure Coils

Of the 125 patients who came for Essure removal, 89 requested Essure reversal to allow them to become pregnant and 36 requested Essure removal because of Essure side effects. All surgeries were performed as outpatient procedures at our specialty center.

No immediate or delayed surgical complications occurred in either our Essure or Adiana surgery patients and most patients reported improvement in their symptoms after Essure removal surgery.

Essure side effects

Most women who have Essure will not experience side-effects; however, some women will experience symptoms which will not resolve. Since Essure sterilization was approved in 2002 there has been a steady increase in the number of women reporting problems after their procedures. The reported side effects are numerous but mostly involve uterine cramping, pelvic pain, pelvic pressure, and abnormal bleeding after the Essure coils have been inserted.

A few women will have more generalized symptoms of joint aches, skin rash, fatigue, decreased libido, and regret.

Often women are told by their health care providers the Essure coils cannot be removed and a hysterectomy is required to treat their symptoms.

Our experience and the experience of 125 of our patients demonstrates Essure coils can be successfully removed during outpatient surgery with minimal risks and without having a hysterectomy.

Can removing Essure help?

If your symptoms started soon after Essure and do not resolve within several weeks then there is a greater chance removal of the Essure coils will improve the symptoms you are experiencing.

We encourage women who are experiencing symptoms to be evaluated by their doctors for other possible causes before considering surgery to remove Essure devices. If other causes cannot be determined then it is reasonable to consider Essure coil removal.

Treatment for Essure problems

For patients who want their Essure coils removed we offer two surgical procedures:

• Essure removal and tubal occlusion (leaving ends separated)
• Essure removal and tubal anastomois (rejoin the tubes)

Each surgery is performed as an outpatient surgery using a small incision made just above the pubic hair line.

Removing Essure coils: Our recommendations

For patients who are having symptoms from Essure, want their coils removed, and who do not wish to become pregnant, we recommend Essure removal and tubal occlusion.

Essure Coils After Removal

This procedure takes 30 to 45 minutes and is performed under general anesthesia. An opening is made into each fallopian tube immediately over the Essure coils. The coils are then removed and care is taken to remove the coils intact.

Each end of the opening created in the tube is then closed (occluded).

The closed ends are left minimally separated in the area where the coils were removed to decrease the possibility of pregnancy.

If you are seeking Essure removal because of pain and cramping then we recommend Essure removal alone and tubal occlusion.

Essure removal and tubal occlusion will help the majority of women who are having Essure related problems.

Removing Essure Coils: Should Tubes Be Rejoined?

Some of our patients have localized symptoms of pain and cramping but also have more generalized symptoms. Many of these patients strongly desire to restore their tubal anatomy to normal after the coils are removed. For these patients we will perform an Essure removal and then a microsurgical tubal anastomosis.

Although pregnancy is not likely after both removing the Essure coils and rejoining the tubes, we caution patients they may be at increased risk of pregnancy with this procedure and, should pregnancy occur, they will be at increased risk for ectopic (tubal pregnancy).

Removing Essure devices: Is pregnancy your goal?

If pregnancy is desired then we recommend Essure reversal utilizing a tubouterine implantation procedure to provide both the best chance of pregnancy and the lowest risk of tubal pregnancy.

Incision After Essure Removal

For more information on Essure reversal: Essure Reversal Surgery: Statistics Update

Essure Problems: We Can Help

Many women have been told they need to have a hysterectomy to treat Essure related symptoms.

Although a hysterectomy may help with Essure side effects, a hysterectomy is an overly aggressive treatment for Essure problems and has greater risks of complications.

For more information about the cost of these Essure removal procedures, please visit: Tubal reversal costs

Women who have additional questions about surgery at our center to remove or reverse Essure are encouraged to call (919) 968-4656 to speak with a knoweledgable staff member.

The post Essure Removal Surgery: Statistics Update appeared first on A Personal Choice.

At A Personal Choice, patients are required to have a body mass index (BMI) of less than
37 for tubal ligation reversal and 45 for vasectomy reversal at least 3 weeks prior to the date of surgery. This policy is for optimal patient safety when undergoing elective outpatient surgery.

BMI

Body mass index (BMI) is a calculation based on height and weight that correlates with the amount of body fat. Calculating your BMI will tell you if you are at a healthy weight. Enter your height and weight in this BMI calculator to determine your body mass index.

Metric Calculator

If your body mass index is higher than the maximal limit, we recommend progressive weight loss through diet combined with regular exercise such as walking daily. Fasting, limiting fluid intake, or using diuretics to lose weight immediately before surgery should be avoided to minimize the risks of surgery and anesthesia.

It is essential that you provide accurate information regarding your height and weight when scheduling surgery and during your anesthesia consultation. Providing inaccurate information about your height and weight, past surgery, or medical conditions may result in your procedure being rescheduled or cancelled.

More about BMI

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Bipolar tubal coagulation

Bipolar Coagulation

Bipolar tubal coagulation is the most popular method of laparoscopic female sterilization in the United States. With this method of tubal ligation, the fallopian tube is grasped between two poles of electrical conducting forceps, and electrical current passes through the tube between the two ends of the forceps. Damage to the tube is limited to the segment between the forceps. Often, two or three adjacent sites are coagulated resulting in loss of approximately 2-3 cm of fallopian tube. Bipolar tubal coagulation is a good method of female sterilization for women who decide to have a tubal reversal procedure. Pregnancy rates after reversal of bipolar tubal coagulation are approximately 60%.

Monopolar Coagulation

Monopolar Coagulation

Monopolar coagulation of the fallopian tubes is less common than bipolar coagulation tubal ligation. The electrical current spreads outward from the coagulating forceps, so monopolar coagulation damages more of the fallopian tube than bipolar coagulation. In most cases, the tube is also cut after it has been coagulated.

When a single site of the tube has been coagulated and divided, tubal reversal can be performed without the need for further diagnostic tests. If multiple sites have undergone monopolar coagulation, screening laparoscopy is recommended to evaluate the tubal lengths remaining for repair. Pregnancy rates after reversal of monopolar coagulation procedures are 40-50%.

Tubal ligation procedures

Normal fallopian tube anatomy and other tubal ligation procedures described in the following pages are:

• Pomeroy Tubal Ligation
• Tubal Rings and Clips
• Monopolar and Bipolar Tubal Coagulation
• Parkland and Irving Procedures
• Fimbriectomy
• Essure and Adiana (Hysteroscopic Procedures)

The post Tubal Ligation Methods – Coagulation appeared first on A Personal Choice.