European Journal of Obstetrics & Gynecology and Reproductive Biology 99 (2001) 219±221
The changes in ovarian hormone levels and ovarian artery blood ¯ow rate after laparoscopic tubal sterilization M. Bulent Tirasa,*, Volkan Noyana, Hakan Ozdemirb, Haldun Gunera, Akgun Yildiza, Mulazim Yildirima a
Department of Obstetrics and Gynecology, School of Medicine, Gazi University, Cicekdagi Sok No. 12/2 GOP, Besevler, 06 700 Ankara, Turkey b Department of Radiology, School of Medicine, Gazi University, Besevler, Ankara, Turkey Received 18 January 2001; received in revised form 4 April 2001; accepted 21 April 2001
Abstract Objective: To investigate the changes in serum ovarian hormone levels and ovarian artery blood ¯ow rate by Doppler ultrasonography following laparoscopic tubal sterilization. Methods: Laparoscopic tubal sterilization have been performed on 13 voluntary subjects between the sixth and eighth days of the menstrual cycle. Serum ovarian hormone levels and ovarian artery blood ¯ow rate, by Doppler ultrasonography, were determined 3 days before the operation, on the post-operative third day and on the post-operative third month. The results of 10 participants who ®nished the follow-up period were analyzed. Results: There were no statistically signi®cant changes in serum levels of ovarian hormones after laparoscopic tubal ligation. The end-diastolic blood ¯ow in ovarian artery was found to be decreased following tubal sterilization (8:7 2:8 and 7:4 1:8 m/sec, respectively, P > 0:05), while resistivity index (RI) increased after the operation (0:7 0:1 and 0:8 0:03, respectively, P > 0:05). Conclusion: There was no change in ovarian hormone levels after laparoscopic tubal sterilization. There is slight but statistically non-signi®cant decrease in ovarian artery blood ¯ow rate following tubal sterilization, signifying a local increase in vascular resistance. # 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Tubal sterilization; Laparoscopy; Ovarian artery blood ¯ow; Ovarian hormones
1. Introduction Laparoscopic tubal sterilization, which is a surgical sterilization procedure is one of the most commonly used contraceptive methods in recent years. It is popular because of its safety, lesser technical dif®culty and short post-operative hospitalization time . It has been reported that irregular menstrual cycles, dysmenorrhea or premature menopause may follow tubal sterilization . These complications are thought to be related to vascular injury of the fallopian tubes and disturbed utero-ovarian circulation. These hemodynamic changes may be irreversible . Some of the studies about endocrine status after tubal sterilization have shown that low serum progesterone levels might be detected in the luteal phase  and some have shown low pre-ovulatory estradiol concentrations . On the other hand, Gentile et al.  in a recent review, stated that tubal sterilization was not associated with an increased risk of menstrual dysfunction, dysmenorrhea or increased pre-menstrual distress before *
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(M. Bulent Tiras).
the age of 30 years. There might be some increased risk for younger women, although they did not appear to undergo signi®cant hormonal changes . There are a few studies in the literature evaluating ovarian and uterine artery blood ¯ow by Doppler ultrasonography before and after tubal sterilization [1,7]. The aim of this study is to investigate serum ovarian hormone levels and ovarian artery blood ¯ow changes by Doppler ultrasonography before and after the operation in women who underwent laparoscopic tubal sterilization. 2. Material and methods About 13 women who attended to Gazi University School of Medicine, Department of Obstetrics and Gynecology for surgical sterilization, were included in the study. All had regular menstrual cycles and in the last 3 months they had not used oral contraceptives or intrauterine devices. The study was approved by the ethical committee and written consents were taken. The participants were sterilized by bipolar cauterization (Bicoag forceps M 3700, 33 cm, Origin, Menlo Park, CA,
0301-2115/01/$ ± see front matter # 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 3 0 1 - 2 1 1 5 ( 0 1 ) 0 0 4 1 0 - 9
M. Bulent Tiras et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 99 (2001) 219±221
Table 1 Pre-operative and post-operative serum pituitary and ovarian hormone levels of the subjects (n 10) Hormone FSH (IU/l) LH (IU/l) PRL (ng/ml) E2 (pg/ml) P (ng/ml) A (ng/ml) DHEA-S (mg/dl) a
Pre-operative 5.25 2.56 7.53 127.3 2.21 1.8 113.6
3.9 1.56 4.0 1.6 3.1 0.8 53
4.22 2.6 4.21 3.0 9.4 4.2 141 74.6 3.2 3.9 1.8 0.9 115.4 38
5.34 5.92 8.3 99 1.61 2.5 117
>0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
1.3 2.0 4.7 55.2 1.75 1.5 44
Table 2 Pre-operative and post-operative ovarian artery color Doppler studies of the subjects (n 10)a Doppler b
PSV (R ) EDV (R) RI (R) PI (R) PSV (Ld) EDV (L) RI (L) PI (L)
Pre-operative 32 8.7 0.7 1.8 34.2 9.0 0.73 1.78
11.3 2.8 0.1 0.4 9.2 1.6 0.1 0.4
32.2 9.0 0.7 1.65 31.2 8.6 0.71 1.75
33.1 7.4 0.8 1.73 34 7.6 0.76 1.78
>0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05 >0.05
8.2 3.1 0.1 0.3 14.6 3.4 0.1 0.3
8.1 1.6 0.03 0.3 6.2 1.8 0.1 0.3
PSV: peak systolic velocity; EDV: end-diastolic velocity; RI: resistivity index; PI: pulsatility index. Right. c Mean S:D: d Left. b
USA) between the sixth and eighth days of the menstrual cycle. All of the operations were held by the same surgeon (BT, the ®rst author). Both of the fallopian tubes were coagulated and cut, 2±3 cm distal to the cornual region by bipolar cutting forceps at one point. Bipolar coagulation was performed at 50 W for approximately 5±6 s until the tissue bleached. Blood samples were taken for ovarian hormone levels and Doppler ultrasound examination were done for ovarian artery blood ¯ow, 3 days before the operation (on the third menstrual day), on the post-operative third day and on the third day of the menstrual cycle in the post-operative third month. Follicle stimulating hormone (FSH), luteinizing hormone (LH), estradiol (E2), progesterone (P), prolactin (PRL), dehydroepiandrostenedion-sulfate (DHEA-S) and androstenedione (A) levels were studied by ELISA and I125 RIA with MAGIA 700 device. Ovarian artery Doppler ¯ow examinations were performed in Gazi University, Department of Radiology by Toshiba SSA-270 A color Doppler ultrasonography device with a 3.75 MHz convex transducer. Spectral Doppler analysis were held in ovarian arteries and maximum systolic ¯ow (PSV), end-diastolic ¯ow (EDV), resistivity index (RI) and pulsatility index (PI) were measured. Three subjects who lost the follow-up for the second postoperative control were discharged from the study. Statistical analysis were performed with one-way ANOVA.
3. Results The mean age of the patients was 33:1 3:9 years. Preoperative and post-operative serum hormone levels were shown in Table 1. No statistically signi®cant difference was found between pre- and post-operative measurements. Doppler ultrasonographic measures of both ovarian arteries were given in Table 2. Although no statistically signi®cant difference was found, there was a slight decrease in EDV and increase in RI measurements. 4. Discussion Laparoscopic tubal sterilization was thought to result in disturbance of the ovarian vascularity and change in hormone levels in the past literature . In a prospective controlled study, Shain et al. compared these effects in three different laparoscopic sterilization procedures. They concluded that bipolar cauterization and Pomeroy ligation resulted in more menstrual irregularities compared to Fallope ring . The aftercoming studies have not con®rmed these ®ndings [9,10]. Thranow et al. studied women undergoing tubal sterilization with Fallope ring or Filshie clip . Menstrual patterns and serum FSH, E2 and P levels of the subjects were examined before the sterilization procedure and on the 3rd, 6th and 12th post-operative months.
M. Bulent Tiras et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 99 (2001) 219±221
They found that both Fallope ring and Filshie clip did not affect the menstrual patterns and ovarian hormone levels. In the present study, we have used bipolar cauterization for tubal sterilization. There was no statistically signi®cant difference in menstrual patterns and serum ovarian hormone levels before and after the operation. The ®rst investigators in the literature using ovarian artery color Doppler assessment for ovarian function were Sumiala et al. . They performed 16 laparoscopic tubal sterilization procedures using Filshie clip and evaluated the participants with ovarian and uterine artery Doppler measurements before the operation and on the 2nd and 90th post-operative days. They found an increase in PI both in ovarian and uterine arteries that could be related to an increase in local vascular resistance after the sterilization procedure. Geber and Captano  had also performed Doppler color ¯ow analysis of uterine and ovarian arteries prior to and after surgery for tubal sterilization. With the Pomeroy technique, 20 women were sterilized via laparotomy and no differences were found between the pre-operative and post-operative Doppler measurements . We have performed one preoperative and two post-operative ovarian artery color Doppler measurements. We have used PSV, EDV, RI and PI for evaluation. We have found a statistically non-signi®cant decrease in these parameters after the operation except for RI. The decrease in the end-diastolic blood ¯ow may be due to the increase in vascular resistance. Also RI measures increased after the operation; although not statistically signi®cant, this increase is thought to be due to increased local vascular resistance. It may be concluded that although laparoscopic tubal sterilization might cause a slight local increase in vascular resistance, it might not result in a signi®cant difference in
ovarian artery blood ¯ow rates and serum ovarian hormone levels in the post-operative period. There is a need for further studies to investigate long-term effects of tubal sterilization on tuba-ovarian vasculature. References  Sumiala S, Pirhonen J, Tuominen J, Maenpaa J. Increased uterine and ovarian vascular resistance following Filshie clip sterilization: preliminary findings obtained with color Doppler ultrasonography. J Clin Ultrasound 1995;23:511.  Rioux JE. Late complications of female sterilization: a review of the literature and a proposal for further research. J Reprod Med 1997;19:329.  Cattanach JF, Milne BJ. Posttubal sterilization problems correlated with ovarian steroidogenesis. Contraception 1988;38:541.  Radwanska E, Headley SK, Dmowski P. Evaluation of ovarian function after tubal sterilization. J Reprod Med 1982;27:376.  Cattanach JF. Oestrogen defficiency after tubal ligation. Lancet 1985;1(8433):847.  Gentile GP, Kaufman SC, Helbig DW. Is there any evidence for a post-tubal sterilization syndrome? Fertil Steril 1998;69:179±86.  Geber S, Captano JP. Doppler color flow analysis of uterine and ovarian arteries prior to and after surgery for tubal sterilization: a prospective study. Hum Reprod 1996;11:1195±8.  Shain RN, Miller WB, Mitchel GW. Menstrual pattern change 1 year after sterilization: results of controlled prospective study. Fertil Steril 1989;52:192.  Rivera R, Gaitan JR, Ruiz R. Menstrual patterns and progesterone circulating levels following different procedures of tubal occlusion. Contraception 1989;40:157.  Sahwi S, Topozada M, Kamel M. Changes in menstrual blood loss after four methods of female tubal sterilization. Contraception 1989;40:387.  Thranow I, Hertz JB, Kjer JJ. Hormonal and menstrual changes after laparoscopic sterilization by Falope rings or Filshie clips. Contraception 1992;57:751.