Infertility is a significant global health issue, characterized by the failure to conceive within 12 months of unprotected intercourse, impacting approximately 15% of couples of reproductive age worldwide (Vander Borght and Wyns, 2018). Tubal disease accounts for 11–67% of female infertility (Carson and Kallen, 2021). Proximal, isthmic, or distal tubal blockage can happen because of pelvic inflammatory disease, genital tuberculosis, pelvic surgery, or adhesions that form after surgery (Roberts, 2023). Selective recanalization can address 10–25% of tubal infertility resulting from proximal tubal blockage (Al-Omari et al., 2018). Female sterilization, particularly tubectomy, is a prevalent permanent contraceptive method in low- and middle-income countries. According to NFHS-4 (2015–16), almost 37% of women of childbearing age in India are sterilized. Nonetheless, 1–3% of women pursue sterilization reversal due to unforeseen circumstances such as child loss, remarriage, or alterations in reproductive intentions (Naskar et al., 2022). Tubal sterilization is the most common way to plan a family in Bangladesh, but 10% of women regret it, and 1% want it reversed (Rahman et al., 2024). Thus, tubal recanalization, a surgical or radiologically guided technique to reestablish tubal patency, is a key fertility-preserving option when assisted reproductive technologies (ART) like IVF are too expensive. Over the course of a hundred years, tubal recanalization changed. After Smith's whalebone bougie dilatation in 1849, microsurgery and minimally invasive laparoscopic and hysteroscopic techniques were developed (Roberts, 2023). Since the 1980s, fluoroscopically guided transcervical fallopian tube recanalization (T-FTR) has had an 85–95% technical success rate and a low rate of complications. Ultrasound-guided and hysteroscopic pregnancy outcomes are comparable, rendering them cost-effective in resource-constrained environments (Seyam et al., 2016). Numerous studies from South Asia and around the world show that tubal recanalization leads to better results. A cohort of 40 Bangladeshi women undergoing post-tubectomy recanalization achieved a 62.5% live birth rate, significantly influenced by anastomosis type and tubal length (Rahman et al., 2024). A study in Kolkata showed that isthmo-isthmic anastomosis and a restored tubal length of more than 6 cm predicted a 69% live birth rate in women under 30 (Naskar et al., 2022). A tertiary-care study in Mangalore found that 47% of women conceived after recanalization, with laparoscopic sterilization being more effective than Pomeroy's method (Rao, 2019). A recent study from North India found that having a tubal length of more than 5 cm after surgery improved pregnancy outcomes (Singh et al., 2024). Several patient characteristics influence recanalization beyond surgical technique. Women under 35 have higher rates of conception and a lower risk of ectopic pregnancy (Shen et al., 2020). Prognostic factors encompass the interval between sterilization and reversal, the type of prior sterilization, the anastomosis site, and the tubal length post-repair (Jayakrishnan and Baheti, 2011). Pelvic inflammatory disease, abdominal surgery, and ectopic pregnancy can also impact patency and fertility (Shen et al., 2020). IVF bypasses tubal disease and, in certain situations, offers enhanced chances of conception; nevertheless, tubal recanalization remains a favorable option for some women. Natural conception, multiple pregnancies from a single intervention, and reduced costs are its advantages (Divakar Rao, 2019). Recanalization doesn't need multiple cycles, close monitoring, or ovarian stimulation like IVF does. In settings with limited resources and among younger women exhibiting favorable tubal and ovarian characteristics, microsurgical or laparoscopic recanalization effectively restores fertility in a cost-efficient manner (Naskar et al., 2022; Singh, 2024). Recanalization is dangerous, even though it has a lot of potential. Reversal can lead to 5–10% ectopic pregnancy, necessitating surgical monitoring (Rahman et al., 2024). The rates of miscarriage are not much higher than in the general population, and most pregnancies that go well end in a live birth (Naskar et al., 2022). When case selection and surgical technique are executed correctly, the operation possesses a significant likelihood of facilitating natural conception. This study investigates reproductive outcomes and predictive factors associated with tubal recanalization in women undergoing sterilization reversal at a tertiary care facility.

The current study was structured as a hospital-based, prospective observational investigation carried out in the Department of Obstetrics and Gynecology at a tertiary care institution. The research was conducted over a duration of two years. The Institutional Ethics Committee granted ethical clearance, and all participants provided written informed consent. Women of reproductive age (20–40 years) who had previously undergone tubal sterilization and subsequently sought fertility restoration were included. The inclusion criteria consisted of normal ovulatory cycles, normal semen parameters of the partner, and the absence of pelvic inflammatory disease, endometriosis, or significant uterine pathology. Women over 40 years old, those with severe pelvic adhesions, bilateral hydrosalpinx, abnormal tubal anatomy, or contraindications to pregnancy were not included in the study. All qualified women underwent tubal recanalization with spinal or general anesthesia. The procedure was executed either through microsurgical technique via laparotomy or through laparoscopy, contingent upon patient suitability and surgical feasibility. Fibrosed segments were removed, and end-to-end anastomosis was done with fine, non-absorbable sutures that followed microsurgical principles very closely. During the operation, methylene blue dye insufflation was used to check if the tubes were open. We wrote down the type of anastomosis (isthmo-isthmic, isthmo-ampullary, or ampullo-ampullary) and the final length of the tube. Patients were monitored for a minimum duration of 12 months following surgery. Ultrasound confirmed clinical pregnancy, and pregnancy outcomes were classified as intrauterine live birth, miscarriage, or ectopic pregnancy. The principal outcome measure was the pregnancy rate within one year. Secondary outcomes encompassed live birth rate, ectopic pregnancy rate, and the correlation of prognostic factors, including age, interval since sterilization, type of sterilization, and reconstructed tubal length, with reproductive outcomes. Statistical Analysis All data were analyzed using SPSS software version 25.0 (IBM Corp., Armonk, NY, USA). Categorical variables, including age groups, type of sterilization, interval between sterilization and reversal, reconstructed tubal length, and site of anastomosis, were expressed as frequencies and percentages. The Chi-square test was applied to evaluate associations between these variables and pregnancy outcomes. A p-value <0.05 was considered statistically significant.

Table 1: Association of Demographic, Surgical, and Anatomical Factors with Pregnancy Outcome after Tubal Recanalization Conceived (n=13) Did not conceived (n=36) p-Value n % n % Age (years) ≤25 years 1 7.69 5 13.89 0.882 26–30 years 8 61.54 18 50.00 31–35 years 3 23.08 9 25.00 >35 years 1 7.69 4 11.11 Type of sterilization Laparoscopic 11 84.62 20 55.56 0.127 Open tubectomy 2 15.38 16 44.44 Interval between sterilization and reversal 0-3 0 0.00 0 0.00 0.585 3-6 10 76.92 22 61.11 6-9 2 15.38 10 27.78 >9 1 7.69 4 11.11 Final length of reconstructed tube ≥4cm 12 92.31 20 55.56 0.041 <4cm 1 7.69 16 44.44 Site of anastomosis Isthmo-isthmic 10 76.92 15 41.67 <0.001 Ampullo-ampullary 0 0.00 11 30.56 Isthmo-ampullary 3 23.08 10 27.78 Table 1 shows the influence of demographic, surgical, and anatomical factors on the reproductive outcomes of women who have undergone tubal recanalization subsequent to sterilization reversal. Of the 49 women, 13 (26.53%) became pregnant, while 36 (73.47%) did not become pregnant following the procedure. The majority of those who conceived were aged 26–30 years (8, 61.54%), followed by 31–35 years (3, 23.08%), ≤25 years (1, 7.69%), and >35 years (1, 7.69%). In the non-conceived group, the majority were aged 26–30 years [18 (50.00%)], indicating that conception occurred more frequently in younger women, although this finding was not statistically significant (p = 0.882). In terms of the type of previous sterilization, conception happened in 11 (84.62%) of the women who had laparoscopic sterilization, while it happened in only 2 (15.38%) of the women who had open tubectomy. Conversely, among individuals who did not conceive, 20 (55.56%) underwent laparoscopic sterilization and 16 (44.44%) underwent open sterilization, suggesting superior fertility restoration following laparoscopic techniques, albeit without statistical significance (p = 0.127). When considering the interval between sterilization and reversal, conception was most frequent when the interval was 3–6 years [10 (76.92%)], followed by 6–9 years [2 (15.38%)] and >9 years [1 (7.69%)]. No pregnancies occurred when the interval was less than three years. In the group that didn't conceive, the numbers were 22 (61.11%), 10 (27.78%), and 4 (11.11%), respectively. This trend indicated improved outcomes with shorter intervals; however, it lacked statistical significance (p = 0.585). A significant correlation was found concerning the final length of the reconstructed tube (p = 0.041). Of the individuals who conceived, 12 (92.31%) exhibited a tubal length of ≥ 4 cm, whereas only 1 (7.69%) had a length of < 4 cm. On the other hand, 20 (55.56%) of women who did not become pregnant had a tubal length of at least 4 cm, and 16 (44.44%) had a tubal length of less than 4 cm. This results shows that keeping the tubal length at the right level is very important for getting pregnant. The location of anastomosis exhibited a highly significant effect (p < 0.001). The isthmo-isthmic anastomosis had the highest pregnancy rate, with 10 (76.92%) women getting pregnant. In contrast, none of the women who had ampullo-ampullary reconnection got pregnant (0 [0.00%]). The isthmo-ampullary type produced moderate outcomes, resulting in 3 (23.08%) conceptions. In the non-conceived cohort, 15 (41.67%) exhibited isthmo-isthmic anastomosis, 11 (30.56%) demonstrated ampullo-ampullary anastomosis, and 10 (27.78%) presented isthmo-ampullary anastomosis.

This study examined reproductive results and prognostic variables after tubal recanalization in sterilized women who sought fertility restoration. One year after follow-up, 13 (26.53%) of 49 women were pregnant. Surgical and anatomical parameters—specifically sterilization method, ultimate tubal length, and site of anastomosis—significantly affected conception outcomes, while demographic ones like age did not. Higher pregnancy rates were strongly connected to laparoscopic sterilization, 4 cm tubal length, and isthmo-isthmic anastomosis. However, shorter sterilization times (3–6 years) were associated with better results, but this was not statistically significant. We found that women aged 26–30 had the highest conception rate (61.54%), although the difference was not statistically significant. It is well known that ovarian reserve and oocyte quality decrease with age, reducing reproductive potential. Shen et al. (2020) found that women under 35 had greater conception rates post-tubal recanalization, while ages over 35 predicted failure. Naskar et al. (2022) found a 69% live birth rate in women under 30, compared to much lower rates in older cohorts. Age did not achieve statistical significance in our study, but the pattern suggests that post-tubal reversal, lower age is reproductively advantageous. In this study, 11 of 13 women (84.62%) who conceived had laparoscopic sterilization, while 2 (15.38%) received open tubectomy. Although not statistically significant in our group, this difference favored laparoscopic procedures clinically. Previous research confirm this. Rao (2019) discovered that 78.5% of laparoscopic sterilization patients became pregnant, compared to 21.5% of open (Pomeroy's) patients. Shah et al. (2024) reported that 87.5% of laparoscopic patients became pregnant, compared to 16% of open patients. Laparoscopic sterilization may be superior since it reduces tube damage, scarring, and length. These factors make recanalization easier and more likely. The interval between sterilization and reversal was not statistically significant (p = 0.585), but pregnancies were most common within the 3–6 year interval (76.92%), suggesting that shorter intervals may improve reproductive results. Jayakrishnan and Baheti (2011) and Naskar et al. (2022) found that conception rates increased with intervals of less than 4–5 years. Progressive tubal fibrosis, scarring, and adhesions may compromise tubal patency and mucosal integrity. Thus, shorter sterilization-reversal times are preferable for pregnancy. Final tubal length was crucial to fertility (p = 0.041). In the study, 12 (92.31%) individuals conceived with a reconstructed tube length > 4 cm, while only 1 (7.69%) conceived with a length < 4 cm. This supports previous research on tubal length's predictive power. Naskar et al. (2022) found that tubal lengths larger than 6 cm predicted live birth, while Singh et al. (2024) and Jayakrishnan and Baheti (2011) found that no women with tubal lengths less 5 cm became pregnant. To optimize gamete transit and fertilization, residual tubal length must be preserved during reversal. The position of anastomosis significantly correlated with pregnancy outcome (p < 0.001). Isthmo-isthmic had the highest conception rate (76.92%), followed by isthmo-ampullary (23)08. None of the ampullo-ampullary anastomosis patients got pregnant. As previously reported by Naskar et al. (2022) and Shah et al. (2024), isthmo-isthmic repairs had greater pregnancy rates than distal (ampullary) reconstructions. The isthmus' stable luminal diameter, stronger muscle wall, and better vascular supply facilitate perfect mucosal alignment and tube function, which improves isthmic anastomosis outcomes. Our study's conception rate of 26.53% is lower than the literature's 40% to 70%, depending on patient selection and follow-up time. Rao (2019) reported a 47% conception rate, while Naskar et al. (2022) reported a 69% Indian cohort live birth rate. Rahman et al. (2024) reported a 62.5% live birth rate for Bangladeshi women after recanalization, while Roberts (2023) found that cumulative pregnancy rates range from 25% to 55%. Our study's lower rate may be attributable to the limited sample size, one-year follow-up, or patient characteristics including tubal difficulties or other health conditions. While in vitro fertilization (I VF) has higher pregnancy rates per cycle, tubal recanalization is still an important fertility-restoring procedure, especially in low-resource settings. It allows for natural conception, financial relief, and many pregnancies without intervention. Tubal recanalization can be cost-effective and patient-satisfying when performed on appropriately selected patients, especially younger women with favorable anatomy, sufficient tubal length, and isthmic obstruction, according to Divakar Rao (2019). Limitations Our study's limitations encompass a relatively small sample size and a brief follow-up period, potentially leading to an underestimation of long-term reproductive outcomes. Additionally, the study was performed in a single tertiary center, and the findings may not be applicable to all contexts. Subsequent investigations involving larger multicentric cohorts and extended follow-up are necessary to corroborate these findings.

This study indicates that successful pregnancy following tubal recanalization is influenced more by surgical and physical characteristics than by demographic factors. While age and sterilization interval did not demonstrate statistical significance, younger women and those with shorter sterilization-to-reversal intervals exhibited superior outcomes. A final tubal length of at least 4 cm and isthmo-isthmic anastomosis were the two most important signs that a woman would be able to obtain pregnant, as they were both linked to positive outcomes. Laparoscopic sterilization was better for postoperative fertility because it caused little damage to the tissue and kept the length of the tubes. To have a successful reproduction, you need to be very careful with your surgical technique, choose the right cases, and think about the length of the tubes and the location of the anastomosis. For younger women who don't have a lot of money, tubal recanalization is a safe, cost-effective, and biologically natural alternative to assisted reproduction.

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