1) Bilateral Tubal Ligation Techniques

Pomeroy Technique
The Pomeroy technique of tubal ligation and resection is the most commonly used method. The
Pomeroy method involves creating and tying off a loop of the fallopian tube. The tied off section
is then surgically removed. The ligatures are designed to dissolve, eventually leaving two sealed
ends. There are variations of the Pomeroy technique, and successful tubal reversal depends on
the length of fallopian tube segments remaining that can be repaired. About two-thirds of the
women who undergo tubal reversal following Pomeroy tubal ligation become pregnant.
Tubal Rings or Clips
Of the methods listed, application of a ring or clip to the tube offers the best outcome following
tubal reversal as it involves the least amount of tubal damage. Tubal ring ligation is similar to the
Pomeroy technique; the main difference is that an elastic ring is used to bind the loop in the
fallopian tube. The constriction of the ring cuts off the blood supply to the tissue in the loop, and
scar tissue forms in its place. The segments of the fallopian tube eventually separate. Tubal
ligation with clips is similar to using rings, except only the tissue compressed by the clips is
damaged. Tubal reversal studies show about two-thirds of patients become pregnant following
this microsurgery procedure.
Tubal Ligation and Resection
The tubal ligation and resection method involves the removal of a portion of the fallopian tube.
This form of tubal ligation is most commonly utilized immediately following delivery (post
partum). Ligatures are used to tie off a section of the fallopian tube, then the section in between
is removed. Typically only one to two centimeters of fallopian tube are taken from the middle of
the tube. This type of tubal ligation is generally amenable to reversal but is dependent on the
length of fallopian tube removed. An estimate of the length of tube that was removed can be
obtained from the pathology report, which is generated at the time of tubal ligation. The
pregnancy rates for tubal reversals of this procedure range from 60 to 70 percent.
Tubal Coagulation
Tubal coagulation is primarily used for laparoscopic tubal ligation procedures. A pair of forceps
that can conduct electricity is used to grasp the fallopian tube at the appropriate point. An
electrical current passes through the forceps and coagulates the blood vessels in adjoining
tissue. There are two main variations on this procedure: bipolar and monopolar coagulation.
Pregnancy rates following tubal reversal of bipolar coagulation are around 60 percent.
Monopolar coagulation tends to damage a larger section of the fallopian tubes, and the tubal
reversal pregnancy rates hover near 40 to 50 percent.
Fimbriectomy
Infrequently, a partial salpingectomy or the removal of the fimbriated end of the fallopian tube
may be used as a method of sterilization. The fimbriae are finger-like projections of the fallopian
tube that move over the surface of the ovary and are critical in picking up the egg at the time of
ovulation. The fimbriae are typically tied, cut, and removed. While some believe this form of
tubal ligation cannot be reversed, new openings can be made in the ends of the tubes.
Pregnancy rates for tubal reversal of fimbriectomy are approximately 30 to 40 percent.

2) Complications of multifetal pregnancy

 Preterm labor and birth. Over 60% of twins and nearly all higher-order multiples are
premature (born before 37 weeks). The higher the number of fetuses in the pregnancy, the
greater the risk for early birth. Premature babies are born before their bodies and organ systems
have completely matured. These babies are often small, with low birthweights (less than 2,500
grams or 5.5 pounds), and they may need help breathing, eating, fighting infection, and staying
 warm. Very premature babies, those born before 28 weeks, are especially vulnerable. Many of
their organs may not be ready for life outside the mother's uterus and may be too immature to
function well. Many multiple birth babies will need care in a neonatal intensive care unit (NICU).
 Gestational hypertension. Women with multiple fetuses are more than twice as likely
to develop high blood pressure of pregnancy. This condition often develops earlier and is more
severe than pregnancy with one baby. It can also increase the chance of placental abruption
(early detachment of the placenta).
 Anemia. Anemia is more than twice as common in multiple pregnancies as in a single
birth.
 Birth defects. Multiple birth babies have about twice the risk of congenital (present at
birth) abnormalities including neural tube defects (like spina bifida), gastrointestinal, and heart
abnormalities.
 Miscarriage. A phenomenon called the vanishing twin syndrome in which more than 1
fetus is diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more likely in
multiple pregnancies. This may or may not be accompanied by bleeding. The risk of pregnancy
loss is increased in later trimesters as well.
 Twin-to-twin transfusion syndrome. Twin-to-twin transfusion syndrome (TTTS) is a
condition of the placenta that develops only with identical twins that share a placenta. Blood
vessels connect within the placenta and divert blood from one fetus to the other. It happens in
about 15% of twins with a shared placenta.