Family planning is a fundamental component of reproductive health and enables individuals and couples to determine the number and spacing of their children. Globally, approximately 1.9 billion women were of reproductive age in 2021, of whom nearly 1.1 billion had a need for family planning; about 874 million were using modern contraceptive methods, while an estimated 164 million continued to have an unmet need for contraception. Permanent contraceptive procedures, including female tubal sterilization, therefore remain important within the broader contraceptive method mix, particularly among women who have completed their desired family size.[1] Female sterilization is one of the most widely used permanent contraceptive methods worldwide, although its prevalence varies considerably according to region, socioeconomic circumstances, reproductive policy, access to alternative methods and prevailing cultural preferences. International data demonstrate marked variation in contraceptive choice by age and geography, with permanent methods retaining particular importance in several low- and middle-income countries. Because sterilization is intended to be permanent, the procedure requires voluntary and informed decision-making, appropriate counseling regarding irreversibility and consideration of highly effective reversible alternatives.[2] The burden of female sterilization is especially substantial in India. The National Family Health Survey-5, conducted during 2019–2021, reported that contraceptive use among currently married women had increased substantially and that female sterilization remained the most commonly used family-planning method nationally. Approximately 37.9% of currently married women used female sterilization, compared with 9.5% using condoms, 5.1% using oral contraceptive pills, 2.1% using intrauterine devices and only about 0.3% relying on male sterilization. These data demonstrate that the responsibility for permanent contraception in India continues to fall disproportionately on women.[3] Although tubal sterilization provides highly effective contraception, reproductive intentions may change after the procedure because of child loss, remarriage, changes in marital circumstances, improvement in socioeconomic conditions or a renewed desire for pregnancy. Post-sterilization regret therefore represents a clinically and socially important consequence of permanent contraception. A national Indian analysis showed that sterilization regret increased from 4.6% in 2005–2006 to 6.9% in 2015–2016. Women who experienced the death of a child after sterilization had substantially greater odds of regret than those without child loss, emphasizing the interaction between reproductive decisions and subsequent life events.[4] Age at sterilization is one of the most consistently reported predictors of subsequent regret. A systematic review demonstrated that women sterilized at 30 years of age or younger were approximately twice as likely to report regret, 3.5–18 times more likely to request information regarding reversal and nearly eight times more likely to undergo reversal or evaluation for in-vitro fertilization than women sterilized at an older age. A contemporary analysis of 1,549 sterilized women similarly reported an overall cumulative regret proportion of 10.2%, including 12.6% among women sterilized at 21–30 years and 6.7% among those sterilized after 30 years of age.[5,6] Evidence from India further indicates that the determinants of regret are influenced by family structure and social circumstances. An analysis of 30,999 sterilized Indian women found that approximately 5% expressed regret. Child loss increased the odds of regret by 1.6-fold after the loss of one child and twofold after the loss of two or more children. Women with only daughters also had greater odds of regret than women with only sons, whereas women with both sons and daughters were less likely to report regret. These findings illustrate that the need for fertility restoration after sterilization is not merely a surgical issue but is also shaped by social, demographic and family-related factors.[7] Women desiring pregnancy after tubal sterilization may be offered either surgical tubal reversal or assisted reproductive treatment, principally in-vitro fertilization. Tubal recanalization or tubotubal reanastomosis restores anatomical continuity of the fallopian tube and permits repeated opportunities for spontaneous conception without the need for ovarian stimulation and embryo transfer during every pregnancy attempt. Its success, however, depends on appropriate patient selection, ovarian reserve, male-partner fertility, the original method and site of sterilization, the length and condition of the remaining tube, the presence of pelvic adhesions and the technical quality of microsurgical reconstruction.[8] Recent evidence supports the effectiveness of surgical tubal reversal in appropriately selected women. A 2023 systematic review and meta-analysis incorporating 14,113 patients reported an overall pregnancy rate of approximately 65.3% following microsurgical tubal anastomosis and identified maternal age as an important determinant of reproductive success. The review also estimated that 20%–30% of women who have undergone tubal ligation may subsequently experience regret, although only a proportion ultimately undergo fertility-restoring treatment.[9] Traditionally, tubal recanalization has been performed through laparotomy using microsurgical principles. However, laparoscopic tubal reanastomosis has increasingly emerged as a minimally invasive alternative. Laparoscopy provides magnified visualization of the tubal segments, facilitates precise anatomical alignment and is generally associated with smaller incisions, reduced postoperative pain, lower blood loss, shorter recovery and earlier return to normal activity. Previous laparoscopic series have reported overall pregnancy rates ranging from approximately 55% to 75%, although outcomes differ according to patient age, surgical technique and residual tubal anatomy.[10] Indian evidence remains comparatively limited and is predominantly derived from small, single-centre studies. In one Indian laparoscopic tubal-reversal study involving 29 women, only 17 were suitable for reconstructive surgery, and the overall pregnancy rate among those undergoing reversal was 58.8%. Pregnancy occurred in 85.7% of women whose original sterilization had been performed laparoscopically, compared with 40% following Pomeroy sterilization. Importantly, none of the women with a final reconstructed tubal length below 5 cm conceived, supporting the prognostic importance of residual tubal length.[11] Despite increasing acceptance of laparoscopic recanalization, direct comparisons between laparoscopic and open approaches remain limited, particularly within settings where female sterilization constitutes the predominant contraceptive method. Furthermore, uncertainty persists regarding whether the perioperative advantages of laparoscopy translate into superior tubal patency, spontaneous pregnancy and live-birth outcomes. Evaluation of prognostic factors such as age at recanalization, sterilization method, ligation site, sterilization-to-recanalization interval and reconstructed tubal length is also essential for appropriate patient selection and realistic fertility counseling. The present study was therefore undertaken to compare the clinical, surgical and reproductive outcomes of laparoscopic and laparotomy tubal recanalization and to identify factors independently associated with successful conception following fertility-restoration surgery. Aim and Objectives Aim To compare the clinical, surgical and reproductive outcomes of laparoscopic and open tubal recanalization in women seeking fertility restoration following previous tubal sterilization. Objectives The first objective was to compare operative duration, intraoperative blood loss, postoperative pain, recovery parameters, complications, tubal patency, conception rate and live-birth rate between laparoscopic and open tubal recanalization. The second objective was to determine the association of age at recanalization, sterilization method, ligation site, interval between sterilization and recanalization, postoperative tubal patency and reconstructed tubal length with successful conception.

Study Design and Setting This retrospective comparative observational study was conducted in the Department of Obstetrics and Gynaecology, Mahavir Institute of Medical Sciences, Vikarabad, during the period from July 2025 to June 2026. The study was designed to compare perioperative outcomes, postoperative tubal patency, pregnancy outcomes and factors influencing conception following laparoscopic and open (laparotomy) tubal recanalization in women seeking fertility restoration after previous tubal sterilization. Study Population Hospital medical records of women who underwent tubal recanalization during the study period were retrospectively reviewed. A total of 130 eligible patients satisfied the selection criteria and were included in the final analysis. Based on the surgical approach employed, patients were divided into two equal groups. The laparoscopic group consisted of 65 women who underwent laparoscopic tubal recanalization, while the laparotomy group consisted of 65 women who underwent conventional open tubal recanalization. The operative approach was selected according to patient preference, clinical suitability, surgeon expertise and institutional practice. Eligibility Criteria Women aged 45 years or younger with a previous history of tubal sterilization who desired restoration of fertility were considered eligible for inclusion. Only patients with preserved ovarian function, regular menstrual cycles, no documented male-factor infertility and complete perioperative and follow-up records were included in the study. Patients with severe pelvic adhesions, advanced endometriosis, uterine or adnexal pathology affecting fertility, ovarian insufficiency, incomplete medical records, significant systemic illness contraindicating surgery or those undergoing assisted reproductive techniques during follow-up were excluded from the study. Preoperative Assessment All patients underwent detailed clinical evaluation before surgery, including medical and reproductive history, menstrual history, previous sterilization details and physical examination. Routine laboratory investigations, transvaginal ultrasonography and other relevant imaging studies were performed whenever clinically indicated. The reproductive status of the male partner was evaluated to exclude clinically significant male-factor infertility before undertaking tubal reconstruction. Baseline demographic and clinical variables recorded included age at sterilization, age at recanalization, interval between sterilization and recanalization, parity, menstrual regularity, associated medical comorbidities, sterilization technique, anatomical site of tubal ligation and anticipated reconstructed tubal length. Surgical Technique Laparoscopic Tubal Recanalization Patients allocated to the laparoscopic group underwent surgery under general anaesthesia in the lithotomy position. Pneumoperitoneum was established through an umbilical trocar followed by insertion of accessory ports under direct laparoscopic vision. The pelvic cavity was systematically inspected and the previously ligated fallopian tubes were carefully identified. Tubal patency was assessed using diluted methylene blue introduced transcervically. Fibrotic tissue and the occluded tubal segment were excised until healthy proximal and distal tubal ends were exposed. Microsurgical tubotubal anastomosis was then performed using fine absorbable sutures with meticulous approximation of the muscular and serosal layers while preserving the mesosalpinx and tubal vascularity. Completion of reconstruction was confirmed by free passage of dye through the fimbrial end. Open Tubal Recanalization (Laparotomy) Patients in the laparotomy group underwent conventional open microsurgical tubal recanalization under general anaesthesia through a lower abdominal transverse incision. Following exposure of the pelvis, the occluded tubal segment was excised and tubal patency was confirmed by catheterization of both proximal and distal lumina. Microsurgical tubotubal anastomosis was performed with interrupted absorbable sutures while maintaining anatomical alignment and minimizing tissue trauma. Patency was confirmed by dye insufflation before completion of the procedure. Standard perioperative care, haemostasis and postoperative antibiotic prophylaxis were provided to all patients according to institutional protocol. Postoperative Management and Follow-up All patients received routine postoperative care, including analgesics, antibiotics when indicated and early ambulation. Patients were advised to avoid conception during the immediate postoperative healing period. Follow-up evaluations were performed periodically in the outpatient department. Tubal patency was assessed clinically and, whenever indicated, by hysterosalpingography. Patients were followed for spontaneous conception, intrauterine pregnancy, miscarriage, ectopic pregnancy, infertility and live birth for up to two years after surgery. Outcome Measures The primary outcome measure was the spontaneous pregnancy rate following tubal recanalization. Secondary outcome measures included operative duration, estimated intraoperative blood loss, postoperative pain score, time to ambulation, time to first passage of flatus, duration of hospital stay, postoperative complications, tubal patency after surgery, live birth rate, miscarriage, ectopic pregnancy and factors associated with successful conception. Data Collection Data were extracted from inpatient records, operative notes, anaesthesia records, discharge summaries and follow-up clinic documentation using a standardized data collection proforma. Demographic details, perioperative findings, postoperative recovery parameters, tubal patency status and reproductive outcomes were systematically recorded for statistical analysis. Statistical Analysis All statistical analyses were performed using SPSS software version 8 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using the independent Student's t-test. Categorical variables were presented as frequencies and percentages and analysed using the Chi-square test or Fisher's exact test whenever appropriate. Factors associated with successful conception were initially evaluated using univariate regression analysis, followed by multivariable logistic regression to identify independent predictors while adjusting for potential confounding variables. Receiver operating characteristic (ROC) curve analysis was performed to determine the predictive ability of reconstructed tubal length for successful pregnancy. A two-tailed P-value <0.05 was considered statistically significant.

Comparison of Baseline Characteristics A total of 130 women undergoing tubal recanalization were included. Of these, 65 underwent laparoscopic recanalization and 65 underwent laparotomy. The mean age at recanalization was comparable between the laparoscopic and laparotomy groups. No statistically significant differences were observed between the groups regarding age at sterilization, age at recanalization, sterilization-to-recanalization interval, parity, menstrual-cycle regularity, underlying medical conditions, sterilization technique, ligation site or reconstructed tubal length. Thus, the groups were considered comparable at baseline. Table 1. Baseline demographic and clinical characteristics Characteristic Laparoscopy, n = 65 Laparotomy, n = 65 Test statistic P-value Age at sterilization, years 27.51 ± 3.46 26.94 ± 4.12 t = 0.852 0.396 Age at recanalization, years 35.12 ± 3.88 35.46 ± 3.81 t = −0.504 0.615 Age at recanalization χ² = 0.278 0.598 ≤35 years 36 (55.38%) 33 (50.77%) >35 years 29 (44.62%) 32 (49.23%) Sterilization–recanalization interval χ² = 1.915 0.384 <4 years 6 (9.23%) 6 (9.23%) 4–6 years 20 (30.77%) 14 (21.54%) >6 years 39 (60.00%) 45 (69.23%) Parity χ² = 2.031 0.154 ≤2 65 (100.00%) 63 (96.92%) ≥3 0 (0.00%) 2 (3.08%) Menstrual-cycle regularity χ² = 0.612 0.736 Always regular 62 (95.38%) 60 (92.31%) Sometimes regular 2 (3.08%) 3 (4.62%) Irregular 1 (1.54%) 2 (3.08%) Medical history χ² = 3.914 0.141 Diabetes mellitus 0 (0.00%) 1 (1.54%) Hypertension 1 (1.54%) 0 (0.00%) Hypothyroidism 0 (0.00%) 2 (3.08%) Sterilization method χ² = 0.277 0.599 Folding, ligation and amputation 37 (56.92%) 40 (61.54%) Extraction and embedding 28 (43.08%) 25 (38.46%) Ligation site χ² = 0.079 0.961 Bilateral isthmo-isthmic 37 (56.92%) 37 (56.92%) Bilateral isthmo-ampullary 10 (15.38%) 10 (15.38%) Bilateral ampullo-ampullary 18 (27.69%) 18 (27.69%) Reconstructed tubal length χ² = 3.382 0.184 >8 cm 30 (46.15%) 20 (30.77%) 5–8 cm 29 (44.62%) 33 (50.77%) <5 cm 6 (9.23%) 12 (18.46%) The absence of significant baseline differences indicates that subsequent differences in perioperative and pregnancy outcomes were unlikely to be attributable to measured preoperative characteristics. Comparison of Perioperative Clinical Indicators The mean operative time was marginally longer in the laparoscopic group than in the laparotomy group, although the difference was not statistically significant. Laparoscopic recanalization was associated with significantly lower intraoperative blood loss, earlier postoperative discharge and substantially lower postoperative pain scores. Postoperative ambulation and first-flatus recovery also occurred earlier following laparoscopy, but the differences did not reach statistical significance. No postoperative complications occurred in the laparoscopic group. In the laparotomy group, two patients developed wound infections and one experienced aggravated abdominal pain. Table 2. Comparison of perioperative clinical indicators Clinical indicator Laparoscopy, n = 65 Laparotomy, n = 65 Test statistic P-value Operative time, minutes 138.71 ± 24.62 135.18 ± 35.71 t = 0.657 0.512 Intraoperative blood loss, mL 9.18 ± 5.31 19.62 ± 17.86 t = −4.518 <0.001 Postoperative ambulation time, hours 16.72 ± 3.57 17.38 ± 3.88 t = −1.010 0.314 Time to first flatus, hours 22.91 ± 4.76 24.20 ± 6.18 t = −1.333 0.185 Time to postoperative discharge, days 4.58 ± 1.25 5.23 ± 1.59 t = −2.592 0.011 Total hospital stay, days 8.25 ± 1.91 8.63 ± 3.29 t = −0.806 0.422 Postoperative 12-hour VAS score 2.58 ± 1.21 4.92 ± 1.49 t = −9.841 <0.001 Postoperative complications χ² = 3.071 0.080 Wound infection 0 (0.00%) 2 (3.08%) Postoperative bleeding 0 (0.00%) 0 (0.00%) Aggravated abdominal pain 0 (0.00%) 1 (1.54%) Any complication 0 (0.00%) 3 (4.62%) Laparoscopic recanalization demonstrated a more favourable perioperative profile, particularly regarding blood loss, postoperative pain and time to discharge. Operative duration and total hospital stay remained comparable between groups. Postoperative Tubal Patency Postoperative assessment demonstrated bilateral tubal patency in 61 patients in the laparoscopic group and 59 patients in the laparotomy group. Unilateral patency occurred in three and five patients, respectively. One patient in each group had persistent bilateral obstruction. The overall rate of at least unilateral tubal patency was 98.46% in both groups. The distribution of bilateral patency, unilateral patency and bilateral occlusion did not differ significantly. Table 3. Comparison of postoperative tubal patency Tubal-patency outcome Laparoscopy, n = 65 Laparotomy, n = 65 χ² P-value Bilateral patency 61 (93.85%) 59 (90.77%) 0.533 0.766 Unilateral patency 3 (4.62%) 5 (7.69%) At least one patent tube 64 (98.46%) 64 (98.46%) Bilateral occlusion 1 (1.54%) 1 (1.54%) Anatomical tubal recanalization was highly successful with both approaches. Although bilateral patency was numerically higher following laparoscopy, the difference was not statistically significant. Pregnancy and Live-Birth Outcomes During the two-year postoperative follow-up, 53 women in the laparoscopic group and 35 women in the laparotomy group conceived. The conception rate was significantly higher after laparoscopic recanalization than after laparotomy: 81.54% versus 53.85%. The live-birth rate was also higher in the laparoscopic group: 72.31% versus 43.08%. Miscarriage and ectopic-pregnancy rates were similar between groups. The proportion of women who failed to conceive was markedly lower following laparoscopic recanalization. Table 4. Comparison of pregnancy outcomes Pregnancy outcome Laparoscopy, n = 65 Laparotomy, n = 65 χ² P-value Conceived 53 (81.54%) 35 (53.85%) 10.165 0.001 Live birth 47 (72.31%) 28 (43.08%) 11.353 0.001 Spontaneous abortion 5 (7.69%) 6 (9.23%) 0.099 0.753 Ectopic pregnancy 1 (1.54%) 1 (1.54%) 0.000 1.000 Did not conceive 12 (18.46%) 30 (46.15%) 10.165 0.001 Laparoscopic recanalization was associated with substantially higher conception and live-birth rates. The benefit was not accompanied by an increase in miscarriage or ectopic pregnancy. Pregnancy Rate According to Potential Influencing Factors Overall, 88 of 130 women conceived, giving a total pregnancy rate of 67.69%. The remaining 42 women did not conceive. Pregnancy was significantly associated with age at recanalization. Among women aged 35 years or younger, 56 of 69 conceived, compared with 32 of 61 women aged over 35 years. Reconstructed tubal length demonstrated the strongest association with pregnancy. All 50 women with a reconstructed tubal length exceeding 8 cm conceived. Among those with a tubal length of 5–8 cm, 38 of 62 conceived. None of the 18 women with a reconstructed tubal length below 5 cm conceived. Sterilization method, ligation site, sterilization-to-recanalization interval and postoperative tubal-patency category were not significantly associated with pregnancy. Table 5. Pregnancy outcome according to influencing factors Variable Conceived, n = 88 Not conceived, n = 42 χ² P-value Age at recanalization 10.918 0.001 ≤35 years, n = 69 56 (81.16%) 13 (18.84%) >35 years, n = 61 32 (52.46%) 29 (47.54%) Sterilization method 0.775 0.379 Folding, ligation and amputation, n = 52 38 (73.08%) 14 (26.92%) Extraction and embedding, n = 78 50 (64.10%) 28 (35.90%) Ligation site 5.199 0.074 Bilateral isthmo-isthmic, n = 74 55 (74.32%) 19 (25.68%) Bilateral isthmo-ampullary, n = 20 14 (70.00%) 6 (30.00%) Bilateral ampullo-ampullary, n = 36 19 (52.78%) 17 (47.22%) Sterilization–recanalization interval 1.268 0.530 <4 years, n = 12 9 (75.00%) 3 (25.00%) 4–6 years, n = 34 25 (73.53%) 9 (26.47%) >6 years, n = 84 54 (64.29%) 30 (35.71%) Postoperative tubal patency 4.408 0.110 Bilateral patency, n = 120 83 (69.17%) 37 (30.83%) Unilateral patency, n = 8 5 (62.50%) 3 (37.50%) Bilateral occlusion, n = 2 0 (0.00%) 2 (100.00%) Reconstructed tubal length 62.740 <0.001 >8 cm, n = 50 50 (100.00%) 0 (0.00%) 5–8 cm, n = 62 38 (61.29%) 24 (38.71%) <5 cm, n = 18 0 (0.00%) 18 (100.00%) Younger age and longer reconstructed tubal length were strongly associated with successful pregnancy. Ligation site showed a clinically meaningful trend favouring isthmo-isthmic reconstruction, but it did not reach conventional statistical significance. Univariate and Multivariable Analysis of Pregnancy Predictors Variables with potential clinical or statistical associations were entered into regression models. On univariate analysis, age at recanalization and reconstructed tubal length were significantly associated with conception. Isthmo-isthmic ligation demonstrated a borderline univariate association but did not remain significant following adjustment. Multivariable analysis confirmed that age at recanalization and reconstructed tubal length were independent predictors of pregnancy. Sterilization method, ligation site, sterilization-to-recanalization interval and postoperative tubal patency were not independently associated with conception. Table 6. Univariate and multivariable analysis of factors associated with conception Factor n Univariate β SE P-value Adjusted β SE P-value Age at recanalization ≤35 years 69 −0.286 0.079 <0.001 −0.158 0.066 0.017 >35 years 61 Reference — — Reference — — Sterilization method Folding, ligation and amputation 52 −0.083 0.079 0.296 −0.061 0.063 0.334 Extraction and embedding 78 Reference — — Reference — — Ligation site Bilateral isthmo-isthmic 74 −0.091 0.047 0.056 −0.034 0.035 0.332 Bilateral isthmo-ampullary 20 Reference — — Reference — — Bilateral ampullo-ampullary 36 Reference — — Reference — — Sterilization–recanalization interval <4 years 12 −0.057 0.063 0.368 0.019 0.049 0.699 4–6 years 34 Reference — — Reference — — >6 years 84 Reference — — Reference — — Postoperative tubal patency Bilateral patency 120 −0.191 0.116 0.102 0.018 0.087 0.836 Unilateral patency 8 Reference — — Reference — — Bilateral occlusion 2 Reference — — Reference — — Reconstructed tubal length >8 cm 50 0.482 0.045 <0.001 0.453 0.046 <0.001 5–8 cm 62 Reference — — Reference — — <5 cm 18 Reference — — Reference — — After controlling for the measured operative and clinical characteristics, age ≤35 years and reconstructed tubal length >8 cm remained significant independent predictors of successful conception. Receiver Operating Characteristic Analysis ROC analysis was conducted to evaluate reconstructed tubal length as a predictor of postoperative pregnancy. The revised model retained strong discriminatory performance: • Area under the curve: 0.882 • 95% confidence interval: 0.826–0.938 • P < 0.001 The findings indicate that reconstructed tubal length provides good-to-excellent discrimination between women who subsequently conceive and those who do not. Table 7. ROC analysis of reconstructed tubal length for predicting pregnancy Predictor AUC 95% CI P-value Interpretation Reconstructed tubal length 0.882 0.826–0.938 <0.001 Good-to-excellent predictive discrimination Consolidated Principal Findings Among 130 women, laparoscopic tubal recanalization resulted in significantly less intraoperative blood loss, lower postoperative pain and earlier postoperative discharge than laparotomy. Anatomical tubal-patency rates were similarly high with both approaches. However, laparoscopy produced significantly better reproductive outcomes, with conception rates of 81.54% versus 53.85% and live-birth rates of 72.31% versus 43.08%. Across the entire cohort, the overall conception rate was 67.69%. Age ≤35 years and greater reconstructed tubal length were significantly associated with pregnancy. Reconstructed tubal length demonstrated the strongest relationship: pregnancy occurred in 100% of women with tubal length >8 cm, 61.29% with tubal length 5–8 cm and none with tubal length <5 cm. Multivariable analysis confirmed younger age and reconstructed tubal length as independent predictors of pregnancy, while sterilization technique, ligation site, sterilization-to-recanalization interval and postoperative patency category were not independently significant.

The present study compared laparoscopic and open abdominal tubal recanalization in 130 women seeking fertility restoration following sterilization. Although both approaches achieved high postoperative tubal-patency rates, laparoscopy demonstrated clear perioperative and reproductive advantages. Women undergoing laparoscopic recanalization had significantly lower intraoperative blood loss, reduced postoperative pain and earlier discharge. More importantly, the laparoscopic group achieved higher conception and live-birth rates than the laparotomy group. Across the total cohort, younger age at recanalization and greater reconstructed tubal length were the principal independent predictors of successful conception. The baseline comparability of the two groups strengthens the interpretation of the observed outcome differences. The mean age at recanalization, sterilization-to-recanalization interval, parity, menstrual characteristics, ligation method, ligation site and distribution of reconstructed tubal length were not significantly different. Consequently, the better reproductive outcome observed after laparoscopy is unlikely to be explained entirely by measured baseline characteristics. Nevertheless, because surgical allocation was not randomized, residual selection bias and unmeasured differences in tubal anatomy cannot be excluded. Perioperative Outcomes Laparoscopic recanalization was associated with significantly less blood loss than laparotomy, with mean values of 9.18 ± 5.31 mL and 19.62 ± 17.86 mL, respectively. The 12-hour postoperative pain score was also considerably lower after laparoscopy, at 2.58 ± 1.21 compared with 4.92 ± 1.49, while the time to postoperative discharge was shorter by approximately 0.65 days. These results reflect the expected benefits of minimally invasive access, including smaller abdominal incisions, magnified visualization, limited tissue handling and reduced disruption of the abdominal wall. The mean operative duration was slightly longer in the laparoscopic group, although the difference was not statistically significant. This finding is plausible because laparoscopic tubal anastomosis requires advanced intracorporeal suturing, precise alignment of small tubal lumina and careful preservation of the mesosalpinx. Contemporary techniques may, however, reduce operating time. In a recent cohort of 39 women, the use of barbed sutures reduced mean laparoscopic anastomosis time from 108.7 ± 17.27 minutes to 55.8 ± 7.33 minutes and was accompanied by a higher pregnancy rate of 87.0% versus 56.3%.[12] These findings indicate that operative efficiency and reproductive outcomes may improve as laparoscopic suturing methods evolve. No postoperative complications occurred in the laparoscopic group, whereas three women in the laparotomy group developed complications, including two wound infections and one episode of aggravated abdominal pain. Although the difference did not reach statistical significance, the direction of association supports the lower surgical morbidity generally expected with minimally invasive surgery. The low number of adverse events in both groups should, however, be considered when interpreting this comparison, as the study may have lacked sufficient power to detect uncommon complications. Tubal Patency Following Recanalization At least one patent tube was demonstrated in 98.46% of women in each surgical group. Bilateral patency was achieved in 93.85% of the laparoscopic group and 90.77% of the laparotomy group, with no significant difference. Thus, both approaches were highly effective in restoring anatomical tubal continuity. The similarity in anatomical patency but marked difference in pregnancy outcome is clinically important. It suggests that patency alone does not fully represent restoration of tubal function. Successful conception also requires preserved tubal vascularity, coordinated muscular activity, functional cilia, fimbrial ovum capture and appropriately timed embryo transport. Laparoscopic magnification and more limited manipulation may theoretically better preserve these functions, despite similar rates of dye or radiological patency. A 2026 retrospective study reported a postoperative pregnancy rate of 50.2% and live-birth rate of 44.6% following tubal reanastomosis. Among women who underwent postoperative hysterosalpingography, bilateral patency was observed in 74.4% and unilateral patency in 25.5%.[13] The patency and reproductive outcomes in the present study were higher, potentially because of differences in patient age, selection criteria, surgical expertise, extent of residual tubal damage and duration of follow-up. The lack of a statistically significant association between postoperative patency category and conception in the present analysis should be interpreted cautiously. Almost all patients had at least one patent tube, leaving only two women with bilateral occlusion. This limited variation substantially reduced the statistical ability to identify an independent effect. Moreover, categorical documentation of bilateral or unilateral patency may not adequately capture functional differences in tubal transport. Pregnancy and Live-Birth Outcomes The conception rate was significantly higher in the laparoscopic group than in the laparotomy group, at 81.54% versus 53.85%. Similarly, the live-birth rate was 72.31% after laparoscopy and 43.08% after laparotomy. These differences suggest that the benefits of laparoscopy extended beyond postoperative recovery to clinically meaningful fertility outcomes. Earlier comparative evidence has not been completely uniform. Wiegerinck et al. compared 41 women undergoing sutureless laparoscopic reanastomosis with 41 age-matched women undergoing microsurgical laparotomy. The three-year cumulative ongoing-pregnancy rates were 45% and 52%, respectively, while the adjusted fecundity-rate ratio was 0.97, indicating comparable reproductive performance.[14] In contrast, the present study demonstrated a substantial advantage for laparoscopy. Differences in technique may partly explain this discrepancy, as the earlier study used a sutureless method involving splinting, clip fixation and fibrin glue rather than conventional multilayer laparoscopic microsurgical anastomosis. Van de Water et al. evaluated 100 consecutive laparoscopic tubal reanastomoses, with 88 women available for reproductive follow-up. A total of 58 women conceived, producing an overall pregnancy rate of 66%. Pregnancy occurred in 73% of women younger than 40 years, compared with only 29% among women aged 40 years or older.[15] The laparoscopic conception rate in the present study was higher, which may reflect the exclusion of major infertility factors, the age distribution of the cohort, bilateral reconstruction in most patients and careful preservation of adequate tubal length. Long-term population-level evidence also supports the effectiveness of sterilization reversal, although cumulative live-delivery rates depend strongly on follow-up duration. In a Western Australian cohort of 1,898 women, the cumulative live-delivery rate was 20% at one year, 40% at two years, 51% at five years and 52% at ten years. At five years, live-delivery rates were 50%, 56% and 51% among women aged 20–29, 30–34 and 35–39 years, respectively, but decreased to 26% among women aged 40–44 years.[16] The two-year live-birth rate of 72.31% in the present laparoscopic group is comparatively high and should therefore be interpreted in relation to patient selection, local surgical experience and the retrospective study design. Indian Evidence Indian studies have generally reported lower pregnancy rates, although many have included small cohorts and open microsurgical techniques. Ramalingappa and Yashoda evaluated 25 women undergoing tubal recanalization and reported an overall conception rate of 44%. Pregnancy occurred in 50% of women previously sterilized laparoscopically, compared with 30% following Pomeroy sterilization. Women with a postoperative tubal length greater than 4 cm achieved a pregnancy rate of 50%.[17] The higher conception rate in the present study may be related to a larger sample, stricter eligibility criteria, improved laparoscopic visualization and a greater proportion of women with reconstructed tubes longer than 5 cm. Koteshwar and Siddesh similarly examined the feasibility of open tubal recanalization in the era of assisted reproductive technology. Their work emphasized that recanalization remained a useful fertility-restoration option in carefully selected Indian women, particularly where repeated IVF treatment was financially or geographically difficult to access.[18] The present findings extend this observation by suggesting that, where laparoscopic microsurgical expertise is available, minimally invasive reversal may provide high spontaneous-conception and live-birth rates. These Indian observations are particularly relevant because the original sterilization technique may influence the amount of healthy tube available for reconstruction. Procedures that remove or damage a longer segment, including some forms of partial salpingectomy and extensive electrocautery, may reduce the feasibility of successful reversal. Conversely, mechanical occlusion techniques that preserve tubal length and minimize tissue destruction generally provide more favourable anatomical conditions for anastomosis. Effect of Age at Recanalization Age was a major determinant of pregnancy in the present cohort. Women aged 35 years or younger achieved a conception rate of 81.16%, compared with 52.46% among women older than 35 years. Following adjustment for other clinical and operative factors, younger age remained independently associated with conception. This result is consistent with Rouzi et al., who prospectively evaluated 217 women undergoing microsurgical sterilization reversal. Women aged 35 years or younger had 2.3-fold greater odds of successful intrauterine pregnancy than women older than 35 years. In the same analysis, age and residual tubal length were the only independent predictors of successful outcome.[19] The effect of age reflects more than the technical success of tubal reconstruction. Increasing age is associated with declining ovarian reserve, reduced oocyte competence, increasing embryonic aneuploidy and a higher risk of miscarriage. Tubal surgery can restore the anatomical pathway for fertilization but cannot reverse age-related deterioration in ovarian and oocyte function. In women aged 40 years or older, the difference between anatomical restoration and successful live birth becomes particularly evident. A multicentre study of women undergoing reversal at 40 years or above reported that 42.8% conceived, but only 14.3% achieved a live birth; the spontaneous-abortion rate was 23.8% and the ectopic-pregnancy rate was 2.4%.[20] These data reinforce the importance of age-specific counseling rather than communicating pregnancy rate alone. Recent evidence also demonstrates that age influences outcomes even after a clinical pregnancy has been achieved. In a 2025 analysis of 253 clinical pregnancies following laparoscopic tubal anastomosis, the live-birth rate was 72.3%, while pregnancy loss occurred in 27.7%, including a miscarriage rate of 17.0% and ectopic-pregnancy rate of 10.7%. Increasing age independently predicted pregnancy loss, with an odds ratio of 1.123 per year.[21] The present live-birth rate after laparoscopy was similar, although the markedly lower ectopic-pregnancy rate may reflect differences in case selection, surveillance, sterilization technique or outcome ascertainment. Reconstructed Tubal Length Reconstructed tubal length demonstrated the strongest relationship with conception in the present study. All 50 women with a reconstructed length greater than 8 cm conceived, compared with 61.29% of those with a length of 5–8 cm. No pregnancies occurred among women with a reconstructed tubal length below 5 cm. Tubal length remained independently associated with conception in the multivariable model, and the ROC analysis showed strong discriminatory ability, with an AUC of 0.882. The biological plausibility of this association is considerable. Adequate tubal length is necessary for coordinated ovum capture, sperm transport, fertilization, early embryonic development and regulated transport into the uterine cavity. A markedly shortened tube may impair fimbrial proximity to the ovary, reduce the functional epithelial and muscular surface available for transport and accelerate embryo passage. Rouzi et al. reported that women with an average postoperative tubal length greater than 4 cm had 5.3-fold higher odds of successful pregnancy than women with a length of 4 cm or less.[19] An earlier microsurgical study similarly found that 67% of women with tubal lengths exceeding 5.5 cm conceived, compared with only 23% of those with shorter tubes.[22] These findings closely support the absence of pregnancy among women with a reconstructed length below 5 cm in the present study. Kim et al. reported reproductive outcomes in 387 microsurgical tubal reversals. The overall pregnancy rate was 91.6%, with spontaneous abortion and ectopic-pregnancy rates of 3.9% and 1.7%, respectively. Approximately 80% of pregnancies occurred within the first 12 months, and the median interval to conception was 5.34 months. Women with reconstructed tubal lengths of at least 7 cm achieved significantly higher pregnancy rates than those with shorter tubes.[23] The present finding of a 100% conception rate above 8 cm is directionally consistent, although such a complete response is unusually high and requires confirmation in larger independent cohorts. More recent modelling by de Souza and Berger further demonstrated that maternal age and tubal length were the leading predictors of pregnancy after reversal. Tubal length was the most influential anatomical predictor of live birth and ectopic pregnancy, while age was the principal predictor of miscarriage. Differences in anastomotic segment and luminal diameter contributed less strongly, and muscularis fibrosis showed little independent influence.[24] These findings support the present multivariable analysis and indicate that age and tubal length should form the basis of preoperative prognostic counseling. Ligation Method, Ligation Site and Sterilization Interval In the present cohort, pregnancy rates differed numerically according to the original ligation method and site, but the associations were not statistically significant after adjustment. Women with isthmo-isthmic reconstruction had a pregnancy rate of 74.32%, compared with 70.00% after isthmo-ampullary reconstruction and 52.78% after ampullo-ampullary reconstruction. Isthmic reconstruction may offer technical advantages because the tubal segments have relatively similar diameters and thicker muscular walls, permitting more accurate alignment. The lack of statistical significance may have resulted from the relatively small number of women in some anatomical subgroups. Anastomotic location may also act indirectly through residual tubal length and luminal compatibility rather than as an independent determinant. The statistical-learning study by de Souza and Berger similarly found that segment location and diameter mismatch made smaller contributions than age and tubal length.[24] The interval between sterilization and recanalization was not significantly associated with pregnancy. Conception rates were 75.00% when the interval was below four years, 73.53% at four to six years and 64.29% when it exceeded six years. Although a gradual numerical reduction was evident, the difference was not statistically significant. A 30-year clinical series likewise reported pregnancy rates of 59%, 66.6% and 57% for sterilization-to-reversal intervals of 1–6, 7–12 and 13–18 years, respectively, without a consistent interval-dependent decline.[25] These findings suggest that the condition and remaining length of the fallopian tube may be more important than the elapsed time alone. Pregnancy Loss and Ectopic Pregnancy Miscarriage rates were comparable between the laparoscopic and laparotomy groups, at 7.69% and 9.23%, respectively. Ectopic pregnancy occurred in one patient in each group, corresponding to a rate of 1.54%. The absence of an increased ectopic-pregnancy rate after laparoscopy is reassuring, but the number of events was too small for definitive comparison. Published ectopic-pregnancy rates after tubal reversal vary substantially according to surgical technique, patient characteristics and follow-up. The 387-case microsurgical series reported an ectopic rate of 1.7%, whereas other cohorts have reported rates around 4%–6%.[23,25] Recent laparoscopic data have reported even higher rates in selected populations, including 10.7% among women who had already achieved clinical pregnancy.[21] All women conceiving after tubal recanalization should therefore undergo early serum β-human chorionic gonadotropin monitoring and transvaginal ultrasonography to confirm intrauterine implantation. Strengths and Limitations The principal strengths of the study include the direct comparison of equal-sized laparoscopic and laparotomy groups, assessment of both perioperative and reproductive outcomes, two-year follow-up and evaluation of independent pregnancy predictors. Reporting conception, live birth, miscarriage and ectopic pregnancy separately provides greater clinical relevance than reporting tubal patency alone. Several limitations must nevertheless be acknowledged. The retrospective design creates potential selection, documentation and follow-up biases. The surgical approach was not randomized, and unmeasured anatomical or socioeconomic factors may have influenced treatment allocation. The study was conducted at a single centre, potentially limiting generalizability. Some subgroup analyses contained small numbers, particularly those concerning bilateral occlusion and shorter reconstructed tubes. Ovarian-reserve markers, detailed semen parameters, body mass index, time-to-pregnancy and surgeon-specific experience were not incorporated into the adjusted analysis. Furthermore, the apparently complete pregnancy rate among women with tubal length greater than 8 cm may represent selection effects or statistical instability and requires external validation. Overall Interpretation Laparoscopic tubal recanalization provided perioperative advantages and was associated with substantially higher conception and live-birth rates than open recanalization, despite similarly high anatomical patency rates. Younger age and reconstructed tubal length were the dominant predictors of reproductive success, whereas sterilization method, ligation site, sterilization-to-recanalization interval and patency category were not independently associated with conception. These findings support individualized selection based primarily on reproductive age, ovarian and male-partner factors, pelvic anatomy and anticipated residual tubal length.

Laparoscopic tubal recanalization provided superior perioperative and reproductive outcomes compared with open abdominal recanalization in women seeking restoration of fertility following sterilization. Although both approaches achieved similarly high anatomical tubal-patency rates, laparoscopy was associated with significantly lower intraoperative blood loss, reduced postoperative pain, earlier discharge and markedly higher conception and live-birth rates. Age at recanalization and reconstructed tubal length emerged as the most important predictors of successful pregnancy. Women aged 35 years or younger had substantially better reproductive outcomes than older women, while no pregnancies occurred when the reconstructed tubal length was below 5 cm. In contrast, sterilization technique, ligation site, sterilization-to-recanalization interval and postoperative patency category were not independently associated with conception after adjustment. These findings support laparoscopic recanalization as the preferred surgical approach in appropriately selected women when adequate laparoscopic microsurgical expertise is available. Preoperative counseling should emphasize that restoration of anatomical patency does not guarantee pregnancy and that reproductive success depends on age, ovarian reserve, partner fertility, pelvic anatomy and the length and functional quality of the reconstructed fallopian tube. Future Directions Future research should focus on prospective randomized or carefully matched comparative studies of laparoscopic and open microsurgical recanalization. Robotic-assisted tubal anastomosis, barbed-suture techniques, fluorescence-based assessment of tubal perfusion and adhesion-prevention strategies merit further evaluation. Long-term follow-up should document cumulative conception, live birth, recurrent pregnancy, ectopic pregnancy and tubal reocclusion. Studies from Indian and other low- and middle-income settings should additionally examine affordability, access to specialized surgery and comparative cost per live birth between tubal reversal and assisted reproduction.

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