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 the age of 30 years. There might be some increased risk

Laparoscopic tubal sterilization, which is a surgical ster-
ilization procedure is one of the most commonly used contra-
ceptive methods in recent years. It is popular because of its
safety, lesser technical dif®culty and short post-operative
hospitalization time [1]. It has been reported that irregular
menstrual cycles, dysmenorrhea or premature menopause
may follow tubal sterilization [2]. 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 [3]. Some of the studies about
endocrine status after tubal sterilization have shown that low
serum progesterone levels might be detected in the luteal
phase [4] and some have shown low pre-ovulatory estradiol
concentrations [5]. On the other hand, Gentile et al. [6] in a
recent review, stated that tubal sterilization was not asso-
ciated with an increased risk of menstrual dysfunction,
dysmenorrhea or increased pre-menstrual distress before
*
Corresponding author. Tel.: ‡90-532-461-44-41;
fax: ‡90-312-466-06-18.
E-mail address: btiras@tr-net.net.tr (M. Bulent Tiras).
for younger women, although they did not appear to undergo
signi®cant hormonal changes [6]. 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
220 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 ˆ 10)

Hormone Pre-operative Post-operative-1 Post-operative-2 P value

a
FSH (IU/l) 5.25  3.9 4.22  2.6 5.34  1.3 >0.05
LH (IU/l) 2.56  1.56 4.21  3.0 5.92  2.0 >0.05
PRL (ng/ml) 7.53  4.0 9.4  4.2 8.3  4.7 >0.05
E2 (pg/ml) 127.3  1.6 141  74.6 99  55.2 >0.05
P (ng/ml) 2.21  3.1 3.2  3.9 1.61  1.75 >0.05
A (ng/ml) 1.8  0.8 1.8  0.9 2.5  1.5 >0.05
DHEA-S (mg/dl) 113.6  53 115.4  38 117  44 >0.05
a
Mean  S:D:

Table 2
Pre-operative and post-operative ovarian artery color Doppler studies of the subjects (n ˆ 10)a

Doppler Pre-operative Post-operative-1 Post-operative-2 P value

b c
PSV (R ) 32  11.3 32.2  8.2 33.1  8.1 >0.05
EDV (R) 8.7  2.8 9.0  3.1 7.4  1.6 >0.05
RI (R) 0.7  0.1 0.7  0.1 0.8  0.03 >0.05
PI (R) 1.8  0.4 1.65  0.3 1.73  0.3 >0.05
PSV (Ld) 34.2  9.2 31.2  14.6 34  6.2 >0.05
EDV (L) 9.0  1.6 8.6  3.4 7.6  1.8 >0.05
RI (L) 0.73  0.1 0.71  0.1 0.76  0.1 >0.05
PI (L) 1.78  0.4 1.75  0.3 1.78  0.3 >0.05
a
PSV: peak systolic velocity; EDV: end-diastolic velocity; RI: resistivity index; PI: pulsatility index.
b
Right.
c
Mean  S:D:
d
Left.

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 post-
operative 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. Pre-
operative and post-operative serum hormone levels were
shown in Table 1. No statistically signi®cant difference was
found between pre- and post-operative measurements. Dop-
pler ultrasonographic measures of both ovarian arteries were
given in Table 2. Although no statistically signi®cant dif-
ference 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 hor-
mone levels in the past literature [1]. In a prospective
controlled study, Shain et al. compared these effects in three
different laparoscopic sterilization procedures. They con-
cluded that bipolar cauterization and Pomeroy ligation
resulted in more menstrual irregularities compared to Fal-
lope ring [8]. The aftercoming studies have not con®rmed
these ®ndings [9,10]. Thranow et al. studied women under-
going tubal sterilization with Fallope ring or Filshie clip
[11]. Menstrual patterns and serum FSH, E2 and P levels of
the subjects were examined before the sterilization proce-
dure 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. [1]. 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 [7] 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 [7]. We have performed one pre-
operative and two post-operative ovarian artery color Dop-
pler 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 statis-
tically 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
221
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
[1] 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.
[2] Rioux JE. Late complications of female sterilization: a review of the
literature and a proposal for further research. J Reprod Med
1997;19:329.
[3] Cattanach JF, Milne BJ. Posttubal sterilization problems correlated
with ovarian steroidogenesis. Contraception 1988;38:541.
[4] Radwanska E, Headley SK, Dmowski P. Evaluation of ovarian
function after tubal sterilization. J Reprod Med 1982;27:376.
[5] Cattanach JF. Oestrogen defficiency after tubal ligation. Lancet
1985;1(8433):847.
[6] Gentile GP, Kaufman SC, Helbig DW. Is there any evidence for a
post-tubal sterilization syndrome? Fertil Steril 1998;69:179±86.
[7] 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.
[8] Shain RN, Miller WB, Mitchel GW. Menstrual pattern change 1 year
after sterilization: results of controlled prospective study. Fertil Steril
1989;52:192.
[9] Rivera R, Gaitan JR, Ruiz R. Menstrual patterns and progesterone
circulating levels following different procedures of tubal occlusion.
Contraception 1989;40:157.
[10] Sahwi S, Topozada M, Kamel M. Changes in menstrual blood loss
after four methods of female tubal sterilization. Contraception
1989;40:387.
[11] Thranow I, Hertz JB, Kjer JJ. Hormonal and menstrual changes after
laparoscopic sterilization by Falope rings or Filshie clips. Contra-
ception 1992;57:751.